GI Flashcards
what are worrying features of PR bleeding?
tachycardic dizziness reduced GCS abdo pain and weight loss vomiting hypotension
initial management of PR bleeding
A-E assessment
abdo exam
PR exam
protoscopy
what is included in the D part of an A-E assessment?
GCS, blood glucose, pupils
what are the key bloods of PR bleeding?
FBC clotting U&Es LFTs group and save or cross match 2 units glucose lactate
what other investigations except bloods are needed in PR bleeding?
stool sample
faecal calprotectin
scoping- colonoscopy, proctosigmoidoscopy
differentials of PR bleeding?
polyps diverticular disease haemorrhoids fissures IBD Cancer
what type of bleeding does a fissue in ano produce?
bright red rectal bleeding
features of fissue in ano history?
Painful bleeding that occurs post defecation in small volumes. Usually antecedent features of constipation
features of fissue in ano exam?
muco-epithelial defect usually in the midline posteriorly
what type of bleeding do haemorrhoids produce?
Bright red rectal bleeding
hx of haemorrhoids?
Post defecation bleeding noted both on toilet paper and drips into pan. May be alteration of bowel habit and history of straining. No blood mixed with stool.
PAINLESS bleeding
examination of haemorrhoids?
Normal colon and rectum. Proctoscopy may show internal haemorrhoids. Internal haemorrhoids are usually impalpable
tx of fissure in ano?
1st line- GTN ointment or distiazem cream
2nd line- botox
3rd line- Internal sphincterotomy
tx of haemorrhoids?
lifestyle advice
small haemorrhoids- injection sclerotherapy or rubber band ligation
external haemorrhoids- haemorrhoidectomy
what are external and internal haemorrhoids?
external- originate below the dentate line
painful, prone to thrombosis
internal- below dentate line
no pain
features of upper GI bleeding?
Haematemesis and/ or malaena
Epigastric discomfort
Sudden collapse
differentials of upper GI bleeding?
oesophageal
- oesophagitis
- cancer
- Mallory Weiss tear
- varices
gastric
- gastric cancer
- gastritis
- gastric ulcer
ABCDE of upper GI bleeding?
admit to hosp
A-E assessment
- B- O2, ABG, sats probe, auscultate
-C- give fluids- 500mls stat, catheter, ?ECG, IV access
E- bleeding elsewhere, abdo pain, signs of chronic liver disease?
Bloods- cross match, FBC, LFTs, U&Es, clotting
what blood is urgently transfused in patients with ongoing bleeding and haemodynamic instability?
O negative blood pending cross matched blood
mx of upper GI bleeding after A-E?
make nil by mouth
correct clotting abnormalities- prothrombin complex if on warfarin or platelets if platelet count <50
fresh frozen plasma to patients who have fibrinogen <1 g/litre, or a prothrombin time (international normalised ratio) or APTT >1.5 times normal
urgent endoscopy within 24 hours
what do patients with suspected varices need prior to endoscopy?
terlipressin and prophylactic abx (quinolones)
mx of Mallory Weiss tear?
resolves spontaneously usually
cause of Mallory Weiss tear?
usually following comiting
cause of oesophagitis?
usually history of GORD symptoms
symptoms of varices?
usually large volume of fresh blood
swallowed blood can cause malaena
what is the risk assessment of acute upper GI bleeding due to varices or peptic ulcer disease?
use the Blatchford score at first assessment, and
the full Rockall score after endoscopy
Blatchford score of 0 may be considered for early discharge- urea, Hb, SBP, HR, presence of maleana, syncope, hepatic disease, Cardiac failure
mx of varices?
NBM fluids +/- blood terlipressin and ABx correct clotting urgent OGD- band ligation if oesophageal varices and N-butyl-2-cyanoacrylate for patients with gastric varices
continued bleeding= TIPS surgery
prevention- propranolol
prescribe LMWH
Ix in change of bowel habit?
Bloods- FBC, U&E, LFT, CRP, TFT, glucose, calcium, iron studies, haematinics Anti-TTG, IgA, anti-endomysial Stool sample AXR Scoping
what is H.Pylori associated with?
peptic ulcer disease
gastric cancer
Bcell lymphoma of MALT tissue
atrophic gastritis
what type of bacterial is H.Pylori?
gram negative bacteria
mx of H.pylori?
eradication may be achieved with a 7 day course of
a PPI + amoxicillin + clarithromycin, or
a PPI + metronidazole + clarithromycin
What is the definition of GORD?
symptoms of oesophagitis secondary to refluxed gastric contents
Mx of endoscopically proven oesophagitis?
full dose PPI for 1-2 months
if response then low dose treatment as required
if no response then double-dose PPI for 1 month
Mx of negative reflux disease?
full dose PPI for 1 month
antacids e.g Gavison
if no response then H2RA or prokinetic for one month
what is barrett’s oesophagus?
metaplasia of the lower oesophageal mucosa, with the usual squamous epithelium being replaced by columnar epithelium
what cancer is increased risk in barrett’s oesophagus?
oesophageal adenocarcinoma
RFs for barrett’s oesophagus?
GORD
male gender
smoking
central obesity
mx of barrett’s oesophagus?
endoscopy recommended every 3-5 years for metaplasia
high dose PPI
for dysplasia- endoscopic mucosal resection
radiofrequency ablation
NICE guidelines for urgent referral for endoscopy?
- all patients with dysphagia
- all patients with upper abdo mass consistent with stomach cancer
- patients >55 with weight loss AND ONE OF:
- upper abdo pain
- reflux
- dyspepsia
non urgent referral for endoscopy?
- haematemesis
- > 55 and treatment resistant dyspepsia or upper abdo pain with low Hb or raised platelets with N&V, wt loss, reflex etc
test for H.pylori?
carbon-13 urea breath test or a stool antigen test
treating patients with dyspepsia who don’t meet referral guidelines?
- Review medications for possible causes of dyspepsia
- Lifestyle advice
- Trial of full-dose proton pump inhibitor for one month OR a ‘test and treat’ approach for H. pylori
RFs for gastric cancer?
H.pylori infection pernicious anaemia smoking blood group A salty/spicy diet
histology of gastric cancer?
signet ring cells
features of gastric cancer?
dyspepsia
N&V
anorexia and weight loss
dysphagia
Ix of gastric cancer?
endoscopy with biopsy
staging: CT or endoscopic USS
PET CT
tx of gastric cancer?
subtotal gastrectomy if proximally sites disease >5-10cm from OG junction
total gastrectomy if tumour <5cm from OG junction
lymphadenectomy
Ix of oesophageal spasm?
upper GI endoscopy oesophageal manometry oesophageal pH studies barium swallow USS
Mx of oesophageal spasm>
dietary modification trial of PPI to rule out GORD nitrates CCBS anti-depressants botox injection surgery
red flags of IBS?
> 60 years old
rectal bleeding
unexplained/unintentional weight loss
FH bowel or ovarian cancer
diagnosis of IBS?
6 months of:
- abdo pain and/or
- bloating and/or
- change in bowel habit
other features of IBS?
usually abdo pain is relieved by defecation altered stool passage worse with eating passage of mucus fatigue nausea backache bladder symptoms
Ix of IBS in primary care?
FBC
ESR/CRP
coeliac screen (TTG antibodies)
mx of IB?
1st line-
pain: antispasmodic e.g. mebeverine
constipation- loperamide
diarrhoea- laxatives but avoid lactulose (use linaclotide if conventional laxatives not working)
2nd line- low dose TCA e.g. amitriptyline
psychological intervention- CBT, hypnotherapy
dietary advice- regular small meals, avoid fizzy drinks, not too much fibre
causes of acute diarrhoea? (<14 days)
gastroenteritis
diverticulitis
antibiotic therapy
constipation causing overflow
causes of chronic diarrhoea?
IBS
IBD
colorectal cancer
coeliac disease
common drugs causing constipation?
iron NSAIDS antimuscarinics- procyclidine, antidepressants antiepileptic drugs antihistamines diuretics opiates
mx of constipation?
bulk forming laxatives- fybogel (ispaghula husk), methylcellulose
osmotic laxatives (soften stool)- lactulose, polyethylene glycol
stimulant laxative- Bisacodyl, senna, sodium picosulfate
stop/treat the caues
complications of constipation?
overflow diarrhoea, acute urinary retention, haemorrhoids
presentation of constipation in very elderly?
nausea/loss of appetite
overflow diarrhoea
urinary retention
delirium/ confusion
2 week wait of colorectal cancer referral?
- Patients >40 years with unexplained weight loss AND abdo pain
- Patients >50 years with unexplained rectal bleeding
- Patients >60 with iron deficiency anaemia OR change in bowel habit
- FOBT positive
who is FOBT offered to?
every 2 years to men and women aged 60-74 years
may be given to younger patients with symptoms of abdo pain and weight loss or change in bowel habit or rectal bleeding
how does FOBT work?
uses antibodies that recognises human haemoglobin
patients with abnormal results offered a colonoscopy
most common locations of colorectal cancer?
rectal (40%)
sigmoid (30%)
3 types of colon cancer?
- sporadic (95%)
- hereditary non-polyposis colorectal carcinoma (HNPCC, 5%)
- Familial adenomatous polyposis (FAP, <1%)
Amsterdam criteria for HNPCC?
- at least 3 family members with colon cancer
- the cases span at least 2 generations
- at least one case diagnosed before the age of 50 years
features of crohn’s disease?
diarrhoea usually non-bloody
weight loss more prominent
upper GI symptoms, mouth ulcers, perianal disease
abdo mass in RIF
extra intestinal features of crohn’s disease?
gallstones (secondary to reduced bile acid reabsorption)
arthritis
erythema nodosum
pyoderma gangrenousm
complications of crohns
obstruction
fistula
strictures
colorectal cancer
pathology of crohn’s?
lesions anywhere from mouth to anus
skip lesions may be present
histology of crohn’s?
- inflammation in all layers from mucosa to submucosa
- increased goblet cells
- granulomas
endoscopy of crohn’s?
deep ulcers
skin lesions
cobblestone appearance
radiology of crohn’s?
strictures- kantors string sign
proximal bowel dilatation
rose thorn ulcers
fistulae
features of UC?
Bloody diarrhoea more common
abdo pain in left lower quadrant
tenesmus
extra intestinal features of UC?
primary sclerosing cholangitis uveitis arthritis erythema nodosum pyoderma gangrenosum
complications of UC?
Risk of colorectal cancer higher in UC than crohns
pathology of UC disease
inflammation always starts at rectum and never spreads beyond ileocaecal valve
CONTINUOUS disease
histology of UC disease
no inflammation beyond submucosa
crypt abscesses
depletion of goblet cells
endoscopy of UC?
widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps
radiology of UC
On barium enema:
loss of haustrations
superficial ulceration, ‘pseudopolyps’
long standing disease: colon is narrow and short -‘drainpipe colon’
mx of crohn’s
inducing remission-
- glucocorticoids
- budesonide
- 5-ASA drugs e.g. mesalazine are 2nd line
maintaining remission- - stopping smoking 1st line- azathioprine or mercaptopurine 2nd line- methotrexate TNF inhibitors- infliximab
surgery
mx of UC (mild and moderate)
proctitis- rectal aminosalicylate e.g. mesalazine
change to oral after 4 weeks if no improvement
oral corticosteroids
maintaining remission with topical or oral aminosalicylate
mx of UC (severe)
should be treated in hospital IV steroids 1st line analgesia fluids IV ciclosporin added if no improvement after 72 hours surgery
what is coeliac disease and the pathology?
an autoimmune disease caused by sensitivity to gluten
repeated exposure leads to villous atrophy which in turn causes malabsorption
associations with coeliac disease?
thyroid disease dermatitis herpetiformis IBS T1DM 1st degree relative with coeliac disease
S&Ss of coeliac disease?
chronic or intermittent diarrhoea failure to thrive or faltering growth prolonged fatigue recurrent abdo pain, crampy or distension sudden or unexpected weight loss unexplained iron-deficiency anaemia
immunology of coeliac disease?
TTG antibodies
Endomyseal antibody
anti-casein antibodies
jejunal biopsy findings of coeliac disease?
villous atrophy
crypt hyperplasia
increase in intraepithelial lymphocytes
lamina propria infiltration with lymphocytes
tx of coeliac disease?
gluten free diet
pneumococcal vaccine- due to association with functional hyposplenism
complications of coeliac disease?
anaemia hyposplenism OP, osteomalacia lactose intolerance gastric lymphoma e.g. MALT subfertility oesophageal cancer
Ix of IBD?
WCC and CRP raised
faecal calprotectin
AXR
colonoscopy
3 fat soluble vitamins that are reduced in malabsorption?
ADEK
A deficiency- poor vision
D- rickets, osteomalacia
K- clotting abnormalities
life-threatening causes of abdo pain?
Perforation Bowel infarct/ischaemia Obstruction Acute pancreatitis AAA Appendicitis Strangulated hernia MI Acute cholangitis Ruptured ectopic Ovarian torsion
key investigations for abdo pain?
bloods- FBC, U&E, LFT, amylase MSU- b-HCG (need to rule out pregnancy) ECG (?MI) Erect CXR (?perforation) AXR (?bowel obstruction) CT KUB (?renal stone) USS (hepatobiliary causes) CT abdo
pathophysiology of acute pancreatitis?
- autodigestion of pancreatic tissue by the pancreatic enzymes, leading to necrosis
causes of pancreatitis?
Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune e.g. polyarteritis nodosa Scorpion venom Hypertriglyceridaemia, calcaemia,hyperthermia ERCP Drugs (azathioprine, mesalazine, furosemide, steroids)
features of acute pancreatitis?
Severe epigastric pain that may radiate through to the back
Vomiting is common
Examination may reveal tenderness, ileus and low-grade fever
Periumbilical discolouration (Cullen’s sign) and flank discolouration (Grey-Turner’s sign)
Ix of acute pancreatitis?
raised amylase seen in 75% hyperglycaemia (less insulin production) serum lipase neutrophilia elevated LDH and AST
causes of false positive amylase?
pancreatic pseudocyst
perforated viscus
acute cholecystitis
DKA
mx of acute pancreatitis?
IV fluids O2 analgesia catheter NBM treat cause
cause of chronic pancreatitis?
alcohol (80%)
genetic- CF, haemochromatosis
ductal obstruction
feature of chronic pancreatitis?
pain is typically worse 15-30 mins following a meal
steatorrhoea
DM develops later
Ix of chronic pancreatitis?
AXR- pancreatic calcification
CT-pancreatic calcification
faecal elastase may assess exocrine function
mx of chronic pancreatitis?
pancreatin- contains protease, lipase, amylase (taken with food)
analgesia- NSAIDs and opiates
SE of pancreatin?
irritation of the mouth
perianal rash
N&V
abdo discomfort
endocrine and exocrine role of the pancreas?
endocrine- regulate blood sugar- insulin, glucagon, somatostatin
exocrine- bicarb and digestive enzymes
surgical causes of acute abdomen?
infective- GE, appendicitis, pyelonephritis, diverticulitis, PID
Inflammatory- pancreatitis, peptic ulcer disease
Vascular- MI, mesenteric ischaemia, ruptured AAA
Traumatic- ruptured spleen
Metabolic- renal/ureteric stones, DKA
what is biliary colic?
pain caused by the gallbladder contracting against a stone lodged in the cystic duct
what is cholithiasis vs cholecystitis vs choledocholithiasis?
Cholithiasis= gallstones in gallbladder
Cholecystitis= inflamed gallbladder due to gallstones (raised WCC and CRP), continuous pain
Choledocholithiasis=gallstones in the common bile duct
RFs for biliary colic?
Fat: enhanced cholesterol synthesis and secretion
Female: Oestrogen increases activity of HMG-CoA reductase
Fertile: pregnancy is a risk factor
Forty
cause of gallstones?
occur due to ↑ cholesterol, ↓ bile salts and biliary stasis
features of biliary colic?
colicky abdominal pain, worse postprandially, worse after fatty foods. The pain may radiate to the right shoulder
nausea and vomiting are common
Ix for gallstones?
Abdo USS
LFTs
mx for biliary colic?
If imaging shows gallstones and history compatible then laparoscopic cholecystectomy
features of acute cholecystitis?
Right upper quadrant pain
Fever
Murphys sign on examination
Occasionally mildly deranged LFT’s (especially if Mirizzi syndrome)
Ix for acute cholecystitis?
1st line- USS
2nd line- cholescintigraphy (HIDA) scan
bloods- WCC, CRP, serum amylase
tx of acute cholecystitis?
IV antibiotics
early laparoscopic cholecystectomy within 1 week of diagnosis
what is ascending cholangitis?
ascending infection of the biliary tree
typically E.coli
Charcot’s triad for cholangitis?
RUQ pain
jaundice
RUQ pain
hypotension and confusion are also common
Mx of cholangitis?
intravenous antibiotics
endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction
complications of cholangitis?
severe sepsis liver abscesses liver failure AKI septic shock
what is the common bile duct formed from?
cystic duct (from gall bladder) and common hepatic duct (from liver)
goes into pancreas to join with pancreatic duct
enters duodenum at sphincter of Oddi
RFs of peptic ulcer disease?
H.Pylori
drugs- NSAIDs, SSRIs, corticosteroids, bisphosphonates
Zollinger-Ellison syndrome- gastrin secreting tumour
features of peptic ulcer disease?
epigastric pain
nausea
duodenal ulcers- pain relieved by eating
gastric ulcers- worsened by eating
Ix of peptic ulcer disease
urea breath test or stool antigen test (tests for H.pylori)
tx of peptic ulcer disease
if H.pylori negative -> PPI (omeprazole) given until the ulcer is healed
if H.pylori positive -> eradication therapy given
features of acute appendicitis?
peri-umbilical pain to RIF
vomiting once or twice
mild pyrexia
anorexia
if perforation -> generalised peritonitis
DRE may reveal boggy sensation of pelvic abscess is present
diagnosis of acute appendicitis?
raised inflammatory markers
neutrophils- predominantly leucocytes
urinalysis- rule out pregnancy, renal colic and UTI
USS
Tx of appendicitis?
appendicectomy
prophylactic IV Abx reduces wound infection
abdo lavage
what is diverticulosis?
multiple outpouchings of the bowel wall, most commonly in the sigmoid colon
what is diverticular disease?
symptomatic diverticulosis
altered bowel habits, colicky left-sided abdo pain, bleeding and bloating
treat with high fibre diet and drain any abscesses
what is diverticulitis?
the infection of a diverticulum
RFs for diverticulitis?
Age Lack of dietary fibre Obesity: especially in younger patients Sedentary lifestyle Smoking NSAID use
features of diverticulitis?
Severe abdominal pain in the left lower quadrant
N&V
Change in bowel habit: constipation is more common
Urinary frequency, urgency or dysuria (10-15%): this is due to irritation of the bladder by the inflamed bowel.
PR bleeding
Symptoms such as pneumaturia or faecaluria
Ix of diverticulitis?
FBC: raised WCC
CRP: raised
Erect CXR: may show pneumoperitoneum in cases of perforation
AXR: may show dilated bowel loops, obstruction or abscesses
CT: this is the best modality in suspected abscesses
Colonoscopy: should be avoided initially due to increased risk of perforation in diverticulitis
tx of diverticulitis?
oral antibiotics, liquid diet and analgesia
if the symptoms don’t settle within 72 hours, or more severe symptoms, the patient should be admitted to hospital for IV antibiotics
features of intestinal obstruction?
colicky abdo pain and vomiting
abdo distension and constipation
peritonism
RFs for obstruction?
malignancy
adhesions
strangulated hernia
volvulus
mx of obstruction?
Abdominal film: small bowel loops with fluid levels
laparotomy
CT if suspect malignancy
what are signs of peritonitis?
tenderness on palpation, guarding and rebound tenderness
patients are usually unwell and distressed, worse on movement
causes of peritonitis?
Appendicitis Ectopic pregnancy Infection with TB Obstruction-colicky pain Ulcer- epigastric pain radiating to shoulder intraperitoneal dialysis
what is spontaneous bacterial peritonitis?
a form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis
features of SBP?
ascites
abdominal pain
fever
Diagnosis of SBP?
paracentesis: neutrophil count > 250 cells/ul
the most common organism found on ascitic fluid culture is E. coli
mx of SBP?
IV cefotaxime
when should Abx prophylaxis be given in patients with ascites?
patients who have had an episode of SBP
patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome
NICE recommend: ‘Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less until the ascites has resolved’
what is acute mesenteric ischaemia and what causes it?
embolism e.g. superior mesenteric artery
classic history of AF
abdo pain is severe, sudden onset and out of keeping with physical exam findings
mx of acute mesenteric ischaemia
urgent surgery is usually required
what is ischaemic colitis?
acute but transient compromise in the blood flow to the large bowel
leads to inflammation, ulceration and haemorrhage
it is more likely to occur in areas such as splenic flexure
Ix of ischaemic colitis?
AXR-thumbprinting due to mucosal oedema/haemorrhage, metabolic acidosis
mx of ischaemic colitis?
fluids analgesia NBM surgery if perforation or haemorrhage thrombolytic therapy, angioplasty
what is acute liver failure?
jaundice, coagulopathy (raised PT time), hepatic encephalopathy and hypoalbuminaemia w/o cirrhosis
causes of acute liver failure?
paracetamol OD
hepatitis
alcohol
acute fatty liver of pregnancy
things to ask in acute liver failure?
history of:
- IVDU
- foreign travel
- tattoos
- sexual history
- alcohol
Ix of acute liver failure?
liver screen: LFTs, FBC, U&E, CRP, clotting
hepatitis serology- HbsAg
EBV and CMV serology
serum ceruloplasmin (Wilson’s disease)
A1AT levels
antimitochondrial, anti smooth muscle, ANA
Transferrin
mx of acute liver failure?
Child-Pugh score- assess prognosis of chronic liver disease
A-E
stop hepatotoxic drugs- NSAIDs, paracetamol, ACEi, erythromycin, statins
prophylactic Abx
IV fluids
lactulose- stops encephalopathy by binding to ammonia
escalate early
mx of paracetamol overdose?
if patients present <1 hour, take activated charcoal to reduce absorption of the drug
Give acetylcysteine if there is a staggered overdose or there is doubt over the time of paragetamol ingestion
what is included in the child pugh score?
bilirubin albumin PT time encephalopathy ascites
what are the investigations for non-alcoholic fatty liver disease?
ALT>AST
ELF test
Fibroscan
liver biopsy if advanced disease
what is primary biliary sclerosis?
a rare liver disease typically presenting in middle-aged women
fatigue and itch
jaundice develops as disease progresses
what is primary sclerosing cholangitis?
inflammation of intra and extra-hepatic bile ducts leading to fibrosis and stricture formation
associated with IBD and cholangiocarcinoma
bilirubin, ALP and gammaGT raised
what is a whipple’s resection?
pancreaticoduodenectomy
how is a hepatocellular carcinoma diagnosed?
CT/MRI
alpha-fetoprotein
Ix of gastroenteritis?
stool sample- include C.diff toxin assay and norovirus PCR
bloods- high WCC, high CRP, high urea
what is pseudomonas colitis most commonly caused by?
C.diff- ciprofloxacin
typically 3-9 days post Abx
Symptoms of pseudomonas colitis?
green, foul smelling stool
progression of pseudomonas colitis?
toxic megacolon
perforation
tx of pseudomonas colitis?
metronidazole
2nd line- oral vancomycin
causes and treatment of oesophageal varices?
portal hypertension (due to liver cirhosis) causes dilated collateral veins tx= beta blockers
mx of haematemesis?
OGD within 24 hours
if varices -> IV terlipressin which constricts the splanchic arteries
Balloon tamponade if doesn’t work
what’s included in the Rockall score?
risk of rebleeding score
- age
- shock
- comorbidity
- endoscopic findings- active haemorrhage
what to do in a severe attack of UC?
do a plain AXR to exclude toxic megacolon (diameter >5.5cm) and assess faecal distribution
complications of UC?
perforation bleeding malnutrition toxic megacolon primary sclerosing cholangitis colon cancer
rash in coeliac disease?
dermatitis herpetiformis
what score is used to assess the severity of acute pancreatitis?
glasgow score PANCREAS PO2 Age >55 Neutrophils Calcium Renal function Enzymes (LDH,AST) Albumin Sugar (BG)
what anti-emetics are obstructed in mechanical bowel obstruction?
metoclopramide as it is prokinetic
signs of acute mechanical intestinal obstruction?
distension tenderness visible peristalsis hernias rectal mass on PR examination tinkling bowel sounds (absent in paralytic ileus)
complications of gallstones?
biliary colic cholestasis empyema obstructive jaundice cholangitis gallbladder perforation and peritonitis gallstone ileus
causes of peritonitis?
Appendicitis Ectopic pregnancy Infection with TB Obstruction- colicky pain Ulcer- epigastric pain radiating to shoulder Peritoneal dialysis
RFs of jaudice?
IVDU Sex workers, MSM Alcohol Travel history Healthcare workers Drugs e.g. paracetamol
blood tests to assess liver synthetic function?
Albumin (decreased)
INR- increased due to impaired synthesis of clotting factors and Vit K malabsorption
blood tests to find cause of liver disease?
FBC Hep B&C virus serology A1AT Copper studies Iron studies- Exclude haemochromatosis Autoantibodies- AMA (PBC), ANA, SMA
complications of liver cirrhosis?
renal failure portal hypertension coagulopathy hepatocellular carcinoma (aFP) hepatic encephalopathy- due to ammonia build up Spontaneous bacterial peritonitis
what is achalasia?
Failure of oesophageal peristalsis and of relaxation of lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach’s plexus i.e. LOS contracted, oesophagus above dilated.
clinical features of achalasia?
dysphagia of BOTH liquids and solids
typically variation in severity of symptoms
heartburn
regurgitation of food - may lead to cough, aspiration pneumonia etc
malignant change in small number of patients
Ix of achalasia?
oesophageal manometry: excessive LOS tone which doesn’t relax on swallowing - considered most important diagnostic test
barium swallow shows grossly expanded oesophagus, fluid level, ‘bird’s beak’ appearance
CXR: wide mediastinum, fluid level
tx of achalasia?
intra-sphincteric injection of botulinum toxin
Heller cardiomyotomy
pneumatic (balloon) dilation
drug therapy has a role but is limited by side-effects
what does diffuse oesophageal spasm produce on barium swallow?
corkscrew appearance
how are the causes of ascites differentiated?
SAAG serum-ascites albumin gradient >11g/L: transudate Indicates portal hypertension Cirrhosis Alcoholic hepatitis Cardiac ascites Massive liver metastases Fulminant hepatic failure Budd-Chiari syndrome Portal vein thrombosis Veno-occlusive disease Myxoedema Fatty liver of pregnancy
<11g/L: exudate- infection, inflammation, malignancy Peritoneal carcinomatosis Tuberculous peritonitis Pancreatic ascites Bowel obstruction Biliary ascites Postoperative lymphatic leak Serositis in connective tissue diseases
mx of ascites?
reducing dietary sodium
fluid restriction is sometimes recommended if the sodium is < 125 mmol/L
aldosterone antagonists: e.g. spironolactone
drainage if tense ascites (therapeutic abdominal paracentesis)
large-volume paracentesis for the treatment of ascites requires albumin ‘cover’
paracentesis induced circulatory dysfunction can occur due to large volume paracentesis (> 5 litres). It is associated with a high rate of ascites recurrence, development of hepatorenal syndrome, dilutional hyponatraemia, and high mortality rate
prophylactic antibiotics to reduce the risk of spontaneous bacterial peritonitis
TIPS surgery may be considered- transjugular intrahepatic portosystemic shunt
features of pancreatic cancer?
classically painless jaundice
Courvoisier’s law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones (
however, patients typically present in a non-specific way with anorexia, weight loss, epigastric pain
loss of exocrine function (e.g. steatorrhoea)
loss of endocrine function (e.g. diabetes mellitus)
atypical back pain is often seen
mx of pancreatic cancer?
a Whipple’s resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas. Side-effects of a Whipple’s include dumping syndrome and peptic ulcer disease
where are pancreatic cancers normally sites?q
head of the pancreas
what is haemochromatosis?
autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation
features of haemochromatosis?
early symptoms include fatigue, erectile dysfunction and arthralgia (often of the hands)
‘bronze’ skin pigmentation
diabetes mellitus
liver: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition)
cardiac failure (2nd to dilated cardiomyopathy)
hypogonadism (2nd to cirrhosis and pituitary dysfunction - hypogonadotrophic hypogonadism)
arthritis (especially of the hands)
signs of liver cirrhosis?
Jaundice – caused by raised bilirubin
Hepatomegaly – however the liver can shrink as it becomes more cirrhotic
Splenomegaly – due to portal hypertension
Spider Naevi – these are telangiectasia with a central arteriole and small vessels radiating away
Palmar Erythema – caused by hyperdynamic cirulation
Gynaecomastia and testicular atrophy in males due to endocrine dysfunction
Bruising – due to abnormal clotting
Ascites
Caput Medusae – distended paraumbilical veins due to portal hypertension
Asterixis – “flapping tremor” in decompensated liver disease
complications of cirrhosis?
Malnutrition
Portal Hypertension, Varices and Variceal Bleeding
Ascites and Spontaneous Bacterial Peritonitis (SBP)
Hepato-renal Syndrome
Hepatic Encephalopathy
Hepatocellular Carcinoma
