GI Flashcards
if active UGI bleed how many units should you Xmatch?
6
what are transfusion criteria following UGI bleed?
Hb <70
platelets <50 and active bleeding
PTT>1.5 transfuse FFP
which score can be done pre-endoscopy to calculate the risk of a re-bleed?
Blatchford score
Which score can be done post endoscopy to predict mortality?
Rockall
What is the management for a non-variceal bleed?
endoscopy:
either heat treatment of dual therapy (adrenaline + other)
PPI if stigmata of bleed on endoscopy
test H pylori
What is the management of a variceal bleed
terlepressin and broad spectrum Abx on presentation
band ligation/ glueing in endoscopy
If unable to contro variceal UGI bleed what tube can be used?
Sengstaken-Blakemore tube
define chronic constipation
stools <3/52
more than 6 months
symptoms- straining/ pain on defecation
what investigations would you send a stool sample for in acute diarrhoea?
MC+S
ova and parasites
cysts
c diff toxin
Using a surgical seive list causes of chronic constipation
(Vascular) Inflammatory/ infective- IBS/ diverticular disease Trauma- obstruction (AI) Metabolic- pregnancy, hypercalcaemia Idiopathic/ iatrogenic- lack of fibre/ activity, opiates neoplastic- colon cancer Congenital- hirschprung degenerative- MS, Parkinsons endocrine- hypothyroid
Using a surgical sieve list causes of diarrhoea
(Vascular)
Inflammatory/ infective- IBS/ diverticular disease/ infection e.g. C diff- viral, bacterial or parasitic, appendicitis
Trauma- short bowel syndrome
AI- crohns
Metabolic- anxiety, pancreatic insufficiency
Idiopathic/ iatrogenic- antibiotic colitis/ laxatives, constipation with overflow
neoplastic- colon cancer
Congenital-
degenerative-
endocrine- hyperthyroid
what food item might you advise patients to avoid during acute diarrhoea?
dairy- risk of future intolerance
when are anti-motility drugs contraindicated in acute diarrhoea?
blood in stool
which pathogens causing acute diarrhoea are more likely to cause reactive complications?
shigella
campylobacter
salmonella
which drug is used to treat C diff
metronidazole
which pathogens cause non-bloody diarrhoea with mid-abdominal pain?
giardia lamblia- explosive, flatulance, dirty water
noravirus/ rotavirus
which pathogens are more likely to cause lower abdo pain/ tenesmus/ bloody diarrhoea?
Campylobacter- petting zoo
shigella
salmonella- can cause TMC
E coli 0157- can cause HUS
What should be avoided in E coli 0157?
antibiotics increase risk of HUS
what is HUS?
haemolytic uraemic sundrome- AKI + haemolytic anaemia
which blood test can be used to test for coelic’s?
anti a-gliadin, total immunoglobulin A, IgA tissue transglutaminase (ttg)
How is hepatitis A spread?
faecal-oral- long incubation period so often difficult to identify cause
investigations for Hep A
IgM
who can get infected with hepatitis D?
anyone already infected with hep D, increases risk of HCC and cirrhosis
what is the first line treatment for chronic hep B?
interferon,
if not tolerated then lifelong NRTI
Patient with Hep B bloods as follows:
sAg +
anti HBs -
anti HBc +
current Hep B infection (sAg marker of current infection, anti HBc not found in vaccine)
Patient with Hep B bloods as follows:
sAg -
anti HBs +
anti HBc +
previous Hep B infection (anti HBs marker of current immunity, anti HBc not found in vaccine)
Patient with Hep B bloods as follows:
sAg -
anti HBs +
anti HBc -
previously immunised against Hep B
what is the prognosis for hep C infection?
poor- some may clear spontaneously
20 years 15% cirrhosis
up to 20% HCC
Pain in RUQ, worse after eating, radiates to back, reduces spontaneously
biliary colic
what is murphy’s sign?
2 fingers pressed on RUQ on inspiration causes pain and arrest of inspiration
not reproducable on L
sign of cholecystitis
RUQ and fever, murphys sign positive
cholecystitis
RUQ pain, fever and jaundice, dark stools and pale urine
cholangitis`- charcots triad
what is the difference between MRCP and ERCP?
MRCP diagnostic, ERCP can be used for treatment too
when should you perform a lap cholecystectomy?
if acute pancreatitis/ recurrent within a week, otherwise 6-8 weeks after symptoms stop
what score can be used in cirrhosis to estimate life expectency?
child-pugh score
what score can be used in decompensated cirrhosis for transplant planning?
MELD score
how often should USS be performed in cirrhosis?
every 6 months + AFP to screen for HCC
What can be used for pruritus in cirrhosis?
antihistamine
list 3 causes of portal hypertension
pre-hepatic: portal vein thrombosis/ extrinsic tumours
hepatic causes: cirrhosis, chronic hepatitis, schistosomiasis
post-hepatic causes: RHF, budd chiari syndrome
what screening should be performed in pulmonary hypertension?
endoscopy for varices, if none 2-3 yearly
if small yearly
if larger prophylactic BB/ banding
screen for HCC and cirrhosis
how much fluid in ascites can be detected by shifting dullness?
1.5L
how much fluid in ascites can be setected on USS?
500ml
Name 3 causes of ascites
cirrhosis
malignancy
HF
how soon after admission should an ascitic tap be performed?
within 24 hours
what does a low serum ascites-albumin gradient (<11g/L) indicate?
peritoneal cause of ascites- malignancy, TB, peritonitis
what does a high serum ascites-albumin gradient (>11g/L) indicate?
portal hypertension cause of ascites:
cirrhosis, HF, nephrotic syndrome
what is the best initial treatment for ascites?
reduced sodium diet
spironolactone
aim for 0.5-1kg wight loss/ day
what should be given following therapeutic paracentesis?
small (<5L) synthetic plasma expander
large (>5L) HAS
which condition is associated with crypt abscesses?
UC
Crohn’s may have what appearance?
cobblestone appearance
Where are Crohns lesions most commonly found?
terminal ileum
which form of IBD has transmural lesions?
Crohn’s
what is faecal calprotectin a marker of?
inflammation in colon
what staging system can be used for Crohn’s?
Crohn’s disease severity index
which medication should be avoided in UC?
loperamide, increases risk of TMC
treatment for mild UC?
5-ASA
no improvement add steroids
treatment for mod UC?
prednisolone + 5-ASA, +/- steroid enemas
treatment for severe UC (systemically unwell + 6+ bowel motions a day)?
IV + rectal steroids +5-ASA
?NBM
examine BD for TMC
if no response consider surgery/ ciclosporin or infliximab to maintain remission
what is used to maintain remission in UC?
5-ASAs (sulphasalazine)
which form of IBD is pANCA +ve?
UC
which form of IBD can present with a RLQ mass?
Crohn’s
list 3 extra-intestinal symptoms of IBD?
large joint arthritis
erythema nodosum
irisitis
pyoderma gangrenosum
what treatments are used in Crohn’s?
only to induce remission not to maintain- no 5-ASA only steroids. No response to steroids infliximab
surgical management for Crohn’s?
resection
Surgical treatment for UC?
resection + restorative protocolectomy 92 operations- 1 to create pouch out of ileus and 1 to attach to anus)
what is the M rule?
for primary biliary cirrhosis
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
LLQ pain increased on eating, decreased on OB
divertticular disease
what investigation is most useful for giving a diagnosis of diverticulosis?
barium enema/ flexible sigmoidoscopy- however should not be done in acute settinng as increased risk of perforation
Name 5 general indications for admitting someone with GI problems
cant control pain cant tolerate oral fluids comorbidities/ frail symptoms persisting after treatment complications
what is management for asymotomatic diverticular disease?
increase fibre intake, avoid NSAIDs
what it the management for diverticulitis?
Broad spectrum antibiotics
pain relief (non-constipating)
fluids
what is the long term management for symptomatic diverticular disease?
analgesia (non-constipating)
laxatives - non stimulant
anticholinergics if over-active sigmoid colon
surgery to resect sigmoid if severe
what is Rosving’s sign?
pain on palpation of LLQ increases pain in RLQ (appendicitis)
which score can be used for appendicitis?
Alvarado score:
<4 unlikely
5-6 observe
7+ operate
what is the treatment for appendicitis?
appendicectomy urgently- contraindications include Crohn’s involving caecum/ very elderly
which is more common: small or large bowel obstruction?
small
Name some causes of SBO?
extrinsic- adhesions, strangulated hernia, volvulus
wall- IBD
luminal- gallstone ileus
name 3 causes of large bowel obstruction
extrinsic- sigmoid/ caecal volvulus, gynae cancer
wall- diverticular, strictures, cancer
luminal- faecal impaction
what would absent BS indicate?
peritonitis (perforation)
which type of bowel obstruction is more likely to present acutely?
SBO
What would tinkling BS indicate?
bowel obstruction
5 radiological findings of SBO?
dilatation >3cm central location valvulae conniventes air fluid levels distally no dilation
radiological appearance of LBO?
caecum >9cm/ rest >6cm
peripheral location
haustra
distally no dilation
management of obstruction
“drip and suck”
IV fluids, gut rest, Ryle’s NG for intestinal decompression (if sigmoid volvulus requires decompression via flex sigmoidoscopy)
how long after surgery can you expect an ileus to take to resolve?
Small bowel 24hrs
large bowel 3-5 days
Causes of an ileus
Vascular- mesenteric artery ischaemia
Inflammatory/ infective- appendicitis/ diverticular disease/ sepsis/ gatroenteritis
Trauma- surgery
(AI)
Metabolic- electrolyte abnormalities (hypo K/Na)
Idiopathic/ iatrogenic- anticholinergics/ narcotics
(neoplastic)
(Congenital)
(degenerative)
(endocrine)
what would differentiate an ileus from an obstruction on Xray?
ileus dilation throughout bowel
what criteria can be used to diagnose IBS?
ROME II criteria
According to the ROME II criteria, how long must symptoms be present for for a diagnosis of IBS?
6 months
what cancer is CA 125 a tumour marker of?
ovarian
where is colorectal cancer most commonly found?
1/3 rectal
1/3 L-sided colon
1/3 other
what other cancers are patients with HNPCC at increased risk of?
endometrial
gastric
what is the most common type of colorectal cancer?
adenocarcinoma
which tumour marker can be used to monitor progression in colorectal cancer?
CEA
What staging is used for colorectal cancer?
Duke's staging A- invasion not through bowel wall B- invasion through bowel wall C- lymph nodes D- distant mets
what screening is available for colorectal cancer?
FOB every 2 years from 60-74
how does an ileostomy appear?
R sided
spouted
green liquid
How does a colostomy appear?
L sided
flush to skin
faecal content
what surgery can be done for rectal cancer?
upper- anterior resection
lower- abdominal perineal resection (permanent stoma needed)
what symptoms may suggest rectal prolapse?
tenesmus/ feeling of incomplete emptying
chronic constipation
slight bleed/ mucus on defecation
what is a complication of rectal prolapse?
ulcers
what may you tell a pregnant lady presenting with haemorrhoids?
they will resolve after delivery
what is the dentate line and why is it important?
2cm above anal verge, haemorrhoids above painless (unless srtangulated) below are lined with squamous cells so will be painful and itchy
what is a primary haemorrhoid?
internal- some bleed but not visible externally
what is a second degree haemorrhoid?
prolapsing- bleed and may pop out but retract spontaneously
what is a third degree haemorrhoid?
prolapsed- requiring manual replacement
what management can be used for haemorrhoids?
non-surgical (grade 2+) sclerotherapy/ band ligation via protoscopy
surgical- haemorrhoidectomy under GA
name a risk factor for perianal abscesses?
immunocompromise/ DM
MSM
IBD
where is 12 o’clock on anal examination?
anterior
which are more common primary or secondary anal fissures?
primary, secondary can be due to IBD
what is the first line management for anal fissures?
analgesia, topical GTN ointment, stool softeners
how do you calculate BMI?
Weight (kg)/ height (m)2
when should nutritional support be offered?
BMI <18.5, loss of >10% body weight in <6 months, reduced absorption, eaten little for 5+ days
what score for malnutrition should be calculated on admission
Malnutrition universal screening tool- should be repeated weekly
if eaten little/ nothing for 5+ days what should be done to avoid refeeding syndrome?
include dietician, start at 50% daily calorie allowance and slowly build up
what deficiency may present with night blindness and immune deficiency?
vitamin a
what deficiency may present with bleeding gums and reduced wound healing?
vitamin C (scurvy)
what deficiency may present with osteoporosis and bow legs?
vitamin D (rickets)
what deficiency may present with anaemia and neuro symptoms?
B12- subacute degeneration of spinal cord
What is GORD?
reflux of gastric contents causing pathological changes in oesophagus (note not just occasional feeling of heartburn)
what happens in Barrett’s oesophagus?
squamous epithleium replaced by columnar, increased risk of adenocarcinoma
what are the 2 most common type of oesophageal cancer?
adenocarcinoma (western countries- Barretts) and squamous cell carcinoma (developing countries- smoking and hot drinks)
where in the oesophagus does SCC occur?
upper 2/3
where in the oesophagus does adenocarcinoma occur?
lower 1/3
what is the most common site of metastasis for oesophageal cancer?
adenocarcinoma- liver
SCC- lung, brain, bone, liver
how would you recognise a hiatus hernia on CXR?
retrocardiac fluid level
what is a complication of hiatus hernias?
ulcer formation-> upper GI bleed
which type of peptic ulcer is more common?
duodenal> gastric
how might a gastric ulcer typically present?
pain soon after food, not reduced by eating
anorexia and weight loss
how might a duodenal ulcer typically present?
pain 2-3 hours after food, relieved by eating therefore often maintain or increase weight
name 3 causes of peptic ulcers?
h pylori infection, NSAID use, stress
what is the test for H pylori?
carbon B urea breath test
stool antigen test
what age of patient presenting with a peptic ulcer would you do an endoscopy in?
> 55/ red flags (including Fe deficiency anaemia)/ epigastric mass
what is the eradication regime for H pylori
PPI+ 2 Abx eg amoxicillin and clarythromycin 7 days
If caused by NSAID use and H pylori negative what is the treatment for peptic ulcers?
PPI 2 months
what is the most common type of gastric cancer?
adenocarcinoma
name 3 risk factors for gastric cancer?
H pylori infection
high salt/ preserved food diet
FAP/ HNPCC
what imaging would you use for gastric cancer?
CT and endoscopy for diagnosis
no PET for staging as does not pick up intra-peritoneal seedlings well therefore laparoscopy
what is the most common type of pancreatic cancer?
ductal adenocarcinoma- may be cystic/ endocrine
where is the most common site for pancreatic cancer?
head of pancreas
which tumour marker can be used for pancreatic cancer?
Ca19.9- also raised in obstructive jaundice
what imaging is used for diagnosis/ staging of pancreatic cancer?
USS for diagnosis- endoscopic USS allows stenting until staging
spiral contrast CT for staging
Whast foods should coeliacs avoid?
wheat, rye and barley
where should biopsies be taken for coeliac’s diagnosis?
4 from distal duodenum
what does I GET SMASHED stand for?
Idiopathic gallstones ethanol trauma steroids mumps autoimmune scorpion stings hyperlipidaemia/ hypothyroidism ERCP drugs (azathioprine, diuretics)
what level of amylase is significant for acute pancreatitis?
> 3x normal/ ?1000U/L
which imaging should be done in acute pancreatitis?
AXR if ?obstruction
CXR for pleural effusion
USS if ?gallstones
contrast CT at 48hrs for necrosis (+ raised CRP)
name 3 other causes of raised amylase
renal failure
ectopic
DKA
perforated duodenal ulcer
treatment of acute pancreatitis
analgesia (NSAIDs good, avoid morphine) NBM+ IVI (Hartmann's ? colloids) NG if vomitting/ NJ if necrosis Abx involve ICU early, may need surgical debridement
What is primary and secondary peritonitis?
primary due to SBP
secondary due to perf
are inguinal hernias more common in men or women?
men
which is more common- indirect or direct inguinal hernia?
indirect
where does an indirect inguinal hernia pass?
through internal inguinal ring and inguinal canal
which hernia should always be repaired?
femoral
where does a femoral hernia pass?
femoral canal (in sheath with femoral artery and vein)
what is an anal fistula?
communication between the anal canal and perianal skin, commonly caused by Crohn’s/ diverticulitis. treated surgically
What is a perianal haematoma?
collection of blood under perianal skin, presents as swelling and pain. Cannot be reduced (ddx= haemorrhoids) conservative management/ surgical evacuation
What is a risk factor for anal cancer?
HPV 16/18
what is FAP?
familial adenomatous polyposis- many polyps, increased risk of adenomas. Autosomal dominant inheritance therefore regular colonoscopies for screening
what is petuz- jeghers syndrome?
autosomal dominant disorder characterised by mucosal pigmentation of lips and gums + intestinal polyps
what might indicate a patient is in hepatic failure?
coagulopathy (INR>1.5)
encephalopathy
Jaundice
ascites
name 3 risk factors for hepatocellular carcinoma?
HBV/ HCV infection
alcoholism
genetic haemochromatosis
what is the most common cause of liver abscesses in the developed world?
secondary to infection in abdomen- Crohns, diverticulitis, appendicitis etc
how might a liver abscess present?
RUQ pain, swinging fever, night sweats, pyrexia unknown origin, jaundice
what is a subphrenic abscess?
accumulation of fluid between diaphragm, liver and spleen often following surgery.
what is the most common cause for chronic pancreatitis?
mostly alcohol use, can be CF or obstruction of pancreatic duct (benign/ malignant)
what are 3 causes of gastritis?
excess alcohol
H Pylori
bile reflux
NSAID use
whata is achalasia?
an oesophageal motility disorder, whereby the bottom of the oesophagus may not relax properly during swallowing. causes dysphagia, regurgitation and chest pain. commonly occurs spontaneously but also after surgery/ as a result of gastric carcinoma.
