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Phase 4 - GR > GI > Flashcards

GI Flashcards

1
Q

What is a hernia

A

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

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2
Q

Main complications of hernias

A

irreducible
obstruction (bowel contents cant pass through)
incarcerated
strangulated

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3
Q

Rfs for inguinal hernia

A

Obesity, constipation, chronic cough, heavy lifting, male

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4
Q

Which inguinal hernia most likely to strangulate? where does this hernia go through? what about the other?

A

indirect (through deep inguinal ring) - these ones are more likely to strangulate!!!

Direct - though posterior wall of inguinal canal

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5
Q

What Ix can be done if unsure about a hernia

A

USS

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6
Q

Usual presentation of hernia

A

lump ± pain (?incarceration)

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7
Q

Non surgical mx of small hernia?

A

watch and wait

stop smoking, weight loss, diet

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8
Q

2 complications of mesh surgery for hernias

A

Recurrence within 5 years = 1%
Wound infection
Intestinal injury

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9
Q

presentation of femoral hernia

A

Lump in groin inferior and lateral to pubic tubercle

*superior and lateral = inguinal

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10
Q

Most common DDx of femoral hernia? how to differentiate OE?

A

Hydrocele - possible to get above on examination

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11
Q

Issue with femoral hernias ?

A

High strangulation rate (20% @ 3 months)

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12
Q

presentation of strangulated hernia?

A

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

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13
Q

Red flags of dyspepsia? name 3

A

Wt loss, recurrent vomiting, dysphagia, chronic bleeding

ALARMS
Anaemia, Loss of wt, Anorexia, Recent onset (if >55), Melaena, Swallowing difficulty

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14
Q

most common causes of dyspepsia

A

Functional - without ulcers (70%)
Peptic ulcers
oesophagitis

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15
Q

Diagnosis of funcitional dyspepsia?

A

ROME criteria

6M Post-prandial fullness, early satiety, epigastric pain/burning + no struc

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16
Q

Name 2 drugs that cause dyspepsia

A 
Nitrates
Bisphosphonates
Corticosteroids
NSAIDs
 - Decrease mucus and bicarbonate secretion
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17
Q

How to PPIs work for dyspepsia?

A

decreases expression of H+/K+ antiporter on luminal membrane of parietal cells

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18
Q

Ix in dyspepsia?

A

FBC for alarm e.g. IDA

Test for h.pylori

Endoscopy (upper GI) if ALARMS or >55 (2 week wait)

Barium swallow may be useful

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19
Q

Lifestyle advice for dyspepsia

A

stop offending drugs, decrease tobacco, avoid aggravating foods, lose weight+ over the counter antacids

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20
Q

eg of a H2 receptor antagonist?

PPI?

A

ranitidine

Omeprazole

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21
Q 
Stomach cells - what do they do? 
Chief cells - 
G-cells 
Parietal cells
D-cells - 
Goblet cells -
A

Chief cells - pepsinogen (to pepsin by HCl)

G-cells - gastrin (antrum)

Parietal cells - intrinsic factor and HCl (fundus + body)

D-cells - somatostatin (antrum)

Goblet cells - mucus + bicarbonate

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22
Q

What stops acid production?

A

somatostatin

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23
Q

describe h pylori

A

G - curved bacillus

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24
Q

Sx of PUD

A

Fullness, bloating, early satiety, epigastric pain/burning

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25
Q

Cause of PUD?

A

H.pylori through mucus layer

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26
Q

Ix for H pylori

A

C13 urea breath test - may be done in primary care

Stool antigen test + CLO test (pink with h.pylori)

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27
Q

Type of anaemia in PUD

A 
iron deficiency 
(bleeding + h pylori uses iron for own growth)
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28
Q

Mx of h pylori

A

PAC - 2 WEEKS

PPI + amoxicillin + clarithromycin, or

PPI + metronidazole + clarithromycin

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29
Q

What things help protect against ulcers

A

Mucus, bicarbonate, prostaglandins

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30
Q

What arteries may be affected by PUD in duodenum ? stomach ?

A

duodenal cap, may erode gastroduodenal artery

Common at lesser curve of stomach , may erode L gastric artery

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31
Q

Differentiate pain caused by DU and GU

A

DU - post prandially (1-3 hours), which is relieved by eating

GU - on eating

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32
Q

If pain radiates to back with ulcers where might it be?

A

posterior duodenal ulcer as related pancreas

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33
Q

What may be cause of PUD if h pylori negative and recurrent ulcers?

A

Zollinger-Ellison syndrome

(gastrin-secreting tumour or hyperplasia of the islet cells in the pancreas causes overproduction of gastric acid, resulting in recurrent peptic ulcers)

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34
Q

PUD ix? when for endoscopy? biopsy?

A

FBC - ID anaemia

H.pylori testing

Endoscopy ONLY IF first presentation >55 or ALARMS

Biopsy if NSAID and H.Pylori -ve as ?Zollinger-Ellison

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35
Q

mx of ulcer that is h pylori -ve NSAID induced

A

PPI or H2RA for 8 weeks

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36
Q

Comps of PUD

A

Haematemesis, melaena if erosion of large blood vessel

Acute abdomen and peritonism with perforation

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37
Q

What is GORD

A

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

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38
Q

What does GORD cause?

A

oesophagitis, ulceration, stricture formation or Barrett’s Oesophagus

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39
Q

Epithelial change in barretts?

A

metaplasia or squamous epithelium to glandular

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40
Q

Some Rfs for GORD

A

pregnancy
obesity
smoking, alcohol, coffee

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41
Q

3 things someone with GORD might present with?

A

Heartburn: burning feeling rising stomach to neck relieved by antacid. Related to meals, posture (lying down), straining

Water brash: excessive salivation

Acid brash: retrosternal discomfort - regurgitation of acid or bile

Odynophagia - painful swallowing related oesophagitis or stricture

Belching

Hoarseness

Cough - particularly at night

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42
Q

Gold standard Ix in GORD? other?

A

Gold standard is endoscopy

FBC to exclude anaemia

Barium swallow for hiatus hernia

Oeseophageal pH monitoring

±CXR

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43
Q

What would make you urgent refer for Ca with GORD?

A

ALARMSAnaemia, Loss of wt, Anorexia, Recent onset (if >55), Melaena (GI bleed), Swallowing difficulty

+ vomiting, Barrett’s oesophagitis, lump

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44
Q

Lifestyle Mx of GORD

A

reduce weight, stop smoking, reduce alcohol, raise bed at night, regular small meals,
Avoid causative drugs

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45
Q

Drugs that affect oesophageal motility?

A

nitrates, anticholinergics, TCA

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46
Q

Drugs that damage mucosa

A

NSAID

bisphosphonates

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47
Q

If you see oesophagitis on endoscopy what drug mx?

A

PPI 2/12

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48
Q

Surgical mx of GORD?

A

Laparoscopic fundoplication

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49
Q

Pres of a hiatus hernia? why?

A

GORD - oesophageal sphincter becomes less competent

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50
Q

Ix for hiatus hernia?

A

CXR
Barium study
Endoscopy

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51
Q

Mx of hiatus hernia

A

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

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52
Q

Mx of oesophagitis

A

2/12 PPI

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53
Q

Name 2 PPIs

A

lansoprazole, omeprazole

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54
Q

2 key Ix for barretts?

A

Endoscope - proximal displacement

Biopsy - histological confirmation of columnarisation

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55
Q

Mx of low vs high grade barretts?

A

Low grade: Lifestyle as for GORD + long term PPI ± ablation

High grade: oesophagectomy

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56
Q

Cell type for Ca of oesophagus?

A

80% SCC (upper ⅔)

or adenocarcinoma (lower ⅓)

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57
Q

Red flags for presentation of oesophageal Ca?

A

Dysphagia (solids>liquids)

Vomiting

Anorexia and weight loss

Symptoms of GI related blood loss e.g. melaema

Symptoms of infiltration - intractable hiccups and persistent retrosternal pain

Upper ⅓ specific - hoarseness and cough - less common

Lymphadenopathy

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58
Q

name 3 Ix for oesophageal Ca

A

FBC, UE, LFT, glucose, CRP

*Endoscopy with brushing and biopsy of lesion

CXR for metastases

CT/MRI of chest and upper abdomen for staging

Double contrast barium swallow - for dysphagia

Bronchoscopy if hoarseness

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59
Q

DDx for dysphagia . name 3

A

Oesophageal: GORD, oesophagitis, oesophageal cancer (food sticking), pharyngeal cancer

Neurological: CVA, achalasia, diffuse oesophageal spasm, MS, MND

Others: pharyngeal pouch, external compression (mediastinal tumour), CREST or scleroderma

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60
Q

what is achalasia

A

Disorder of motility of lower oesophageal sphincter

  • Smooth muscle layer has impaired peristalsis and sphincter fails to relax
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61
Q

3 Ix for achalasia? which is gold standard?

A

CXR
Barium swallow
Manometry - gold
[Tube passed into the oesophagus - measures pressure at rest / swallowing]

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62
Q

Seen on CXR of achalasia?

A

, vastly dilated oesophagus behind heart

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63
Q

Seen on barium swallow achalasia?

A

characteristic bird’s beak dilated oesophagus with distal narrowing

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64
Q

Drug mx of achalasia?

A

CCB/nitrates - botox injection

reduce pressure in lower oesophageal sphincter

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65
Q

Surgery for achalasia is normally endoscopic dilation - main comp?

A

perforation

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66
Q

Gi features of scleroderma?

A

Reflux oesophagitis, delayed gastric emptying, Watermelon stomach (- may cause GI bleeding / anaemia)

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67
Q

3 autoantibodies in scleroderma

A

Anti-topoisomerase 1

Anti-centromere antibody (ACA)

Anti-RNA polymerase III

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68
Q

Gi mx of scleroderma

A

lifestyle - like GORD
PPI
Pro-motility agents - metoclopramide or domperidone
Dilatation of oesophaeal strictures

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69
Q

3 DDx of upper GI bleed?

A

PUD, mallory weiss, malignancy, varicies

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70
Q

What to think if Haematemesis is bright red? coffee?

A

Bright red - fresh - above stomach, active haemorrhage

Altered - coffee ground - stomach or below

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71
Q

cause of mallory weiss?

A

Persistent vomiting/wretching

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72
Q

Ix of mallory weiss

A

Endoscopy, FBC including HCT to assess severirt
Renal function/urea for fluid replacement
Cross-match and blood group

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73
Q

2 comps of mallory weiss

A

aspiration pneumonia
Mediastinitis is perforation
Hypovolaemic shock / death

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74
Q

What are oesophageal varicies?

A

Dilated veins at junction between portal and systemic venous circulation account for 10% of UGI bleeds

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75
Q

What usually is the cause of oesophageal varicies?

A

chronic liver disease -> portal hypertension

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76
Q

Ix in varicies?

A

Endoscopy, FBC (Hb and HCT), clotting, renal function, LFT

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77
Q

OE upper GI bleed?

A 
Assess blood loss + look for signs of shock
Pallor and anaemia
Pulse + 
BP
Cool extremities, chest pain, confusion
Dehydration
Stigmata of liver disease
78
Q

3 Ix in upper GI bleed

A

*Endoscopy post resuscitation or within 24 hours

FBC: measure haemoglobin 4 hourly, platelets >50 requires platelet transfusion and FFP for coagulation factors

Crossmatch blood 2-6 units

Coagulation profile: PTT and aPTT - coagulopathy may occur with UGIB

LFT for liver disease

UE + Ur + Cr - serum urea nitrogen:criteria > 30 -> UGIB

CXR (perf oesoph), erect and supine AXR

79
Q

Initial Mx of upper GI bleed if shocked?

A

fluid resuscitation + high flow O2

2 wide bore cannula and send bloods (FBC/UE/LFT/crossmatch/coag)

Fluid bolus 500ml over 15 mins (up to 2L) while waiting for bloods

Transfuse with blood, platelets (<50), FFP (INR or APTT >1.5x normal), prothrombin complex (if warfarin) according to major haemorrhage protocol

CXR, ECG, ABG, catheter, regular monitoring

80
Q

What score system for mortality in upper GI bleed?

A

Rockall

(Age: 60-80 = 1, 80+ = 2
Shock: tachycardia PR > 100 = 1, hypotension = 2
Co-morbidity: heart (IHD, HF) = 2, renal/liver/malignancy = 3)

81
Q

What has to be done post upper GI bleed and when?

A

endoscopy <24 hours

82
Q

name 2 mx options of acute non variceal bleed? eg PUD

A

Mechanical clips
Thermal coagulation with adrenaline
Fibrin or thrombin with adrenaline

83
Q

mx of oestophageal variceal bleed?

gastric?

A

band ligation

Endoscopic injection of N-butyl-2-cyanoacrylate

84
Q

Bowel obstruction presentation

A

nausea / vomiting
pain
failure to pass bowel movements
distension

85
Q

bowel sounds in obstruction?

A

high pitched

86
Q

What does a silent bowel indicate?

A

ileus

87
Q

ix in obstruction / ileus?

A

Bloods: FBC, UE, Cr, group and crossmatch

Fluid charts to monitor intake and output

Plain AXR - supine and erect

88
Q

Seen on AXR in obstruction?
paralytic ileus?
perforation?

A

Distended loops of bowel proximal to obstruction

Fluid levels and distended small bowel throughout = paralytic ileus

Gas under diaphragm = perforation

89
Q

Mx of uncomplicated obstruction?

A

fluid resus + correct electrolytes, intestinal decompression e.g. endoscopy, NG Tube (Sip & Suck)

90
Q

No diagnosis in obstruction mx?

A

= laparotomy + consent for stoma

91
Q

When does sigmoid volvulus occur?

A

in chronic constipation

92
Q

Main complication of signoid volvulus

A

Venous infarction leading to perforation and faecal peritonitis - *shock and temp

93
Q

Seen on AXR of sigmoid volvulus? other Ix for what?

A

*coffee bean sign - grossly dilated sigmoid loop

CT scan to assess bowel wall ischaemia

94
Q

Mx of signoid volvulus? if recurrent?

A

Urgent admission and decompression - pass sigmoidoscope+ flatus tube alongside (in place for 24 hours)

Elective surgery for recurrence - resection of sigmoid colon

95
Q

what happens in paralytic ileus? who is it in normally?

A

no peristalis - bowel just basically packing in

  • occurs in elderly with co morbidities
96
Q

how to avoid vomiting in mx of paralytic ileus?

A

resus through NG tube

97
Q

What is ogilivie’s abdomen?

A

Acute colonic pseudo-obstruction associated with massive dilatation in absence of mechanical obstruction

98
Q

Sx / signs of ogilivie’s

A

Abdo pain, bloating, N+V, intermittent constipation, no faeces or flatus
massive distension

99
Q

Seen on AXR of ogilives

A

MEGACOLON

massive distension

100
Q

mx of ogilives?

A

Treat cause

IV fluids - NBM

Endoscopic decompression
NG tube for decompression if vomiting

[Antiemetic prokinetic e.g. metoclopramide
IV neostigmine (AChE inhibitor) + IV fluids + ABX ± decompression with flexible scope]

Mx of electrolyte imbalance

Surgery if required

101
Q

What is hirschprugs

A

Absence of parasympathetic ganglion cells in myenteric and submucosal plexus of rectum

102
Q

Usual Dx of hirschrungs is when?

A

abdominal distension and failure to pass meconium within 48 hrs

103
Q

Ix in hirschsprung’s ? In older children?

A

AXR - dilated lower bowel

Rectal biopsy - absence of ganglionic cells

older children- anal manometry

104
Q

triad of gastro osophageal obstruction

A

Wretching (no vomiting)
Pain
Failed attempt to pass NG tube

105
Q

Pres / signs of intra abdo abscess?

peritonitis?

A

Abscess: fever + pain (psoas = flank to groin)
Signs: swinging pyrexia + palpable mass

Peritonitis: pain + anorexia + nausea + vomiting
Signs: high fever, tachycardia, tenderness on palpation, guarding, rebound tenderness

106
Q

Ix in Peritonitis/intra-abdominal sepsis

A

FBC: leukocytosis, UE: dehydration, LFT, amylase, lipase: panc,
blood culture,

peritoneal fluid (culture and amylase level),

imaging: AXR, CXR (air under diaphragm)

107
Q

Mx of abdo abscess

A

broad spec ABX: metronidazole + 3rd gen ceph + surgical drainage

108
Q

Mx of peritonitis

A

IV fluid, IV ABX metronidazole + cefotaxime then open or laparoscopic surgery

109
Q

what is an anal fissure? how does it present?

A

Tear in mucosa of anal canal

Pain on defecation (shards of glass), bright red blood on stool or paper

110
Q

mx of anal fissure

A

Adult = bulk forming ispaghula husk, child = osmotic e.g. lactulose)

dietry fibre, adequate fluid

GTN ointment

111
Q

ix / mx of anal fistula

A

MRI

Fistulotomy and excision

112
Q

Ix in anorectal abscess ? MX?

A

Digital rectal exam
MRI - for fistula

Prompt drainage, medication for pain, ABX

113
Q

What is a pilonidal sinus? mx?

A

Top of bum crack

[Small hole or tunnel at skin caused by obstruction of hair follicles at natal cleft which may lead to abscess formation and sinus]

Excision of sinus tract and primary closure
Advise: hygiene and hair removal

114
Q

What does a perianal haematoma look like? bleed / pain?

A

2-4mm dark blueberry under skin

pain common
bleeding uncommon

115
Q

mx of perianal haematoma

A

excise under LA or leave for 5 days

116
Q

Why do haemorrhoids not hurt but perianal haematoma does?

A

haemorrhoids Painless as above dentate line therefore visceral innervation

below dentate line - inferior rectal nerve

117
Q

pres of haemorrhoids

A

Bright red painless rectal bleeding on defecation

118
Q

Ix of haemorrhoids

A

digital rectal exam

proctoscopy

119
Q

Mx haemorrhoids

A

prevent constipation

rubber band ligation

haemorrhoidectomy

120
Q

what is a positive rovsings sign

A

palpation of LLQ increases pain in RLQ (stretches peritoneal lining

121
Q

DDx appendicitis. Name 3

A

GI obstruction, constipation, perforated ulcer, Meckel’s, diverticulitis, Crohn’s
Urological: torsion, calculi, UTI
Gynae: ectopic, ovarian cyst, PID
DKA

122
Q

Ix in appendicitis

A

Urinalysis (UTI), pregnancy test, FBC (raised WCC), CRP, USS

123
Q

Mx appendicitis

A

Laparoscopic or open appendicectomy

IV fluids + opiate analgesia

IV metronidazole and third gen cephalosporin

124
Q

What is diverticular disease? where common?

A

A herniation of mucosa through thickened colonic muscle, common at sigmoid and descending colon

125
Q

Complications of diverticular disease

A

Perforation, obstruction, fistula, abscess, stricture

haemorrhage

126
Q

Ix in diverticular disease - Name 3

A

*Colonoscopy to rule out CoCa

Flexisig @ bleed

FBC - normal at uncomp, raised WCC at diverticulitis, bleeding - raised Pt and anaemia

Uncomplicated - BaEnema

CXR (upright) for pneumoperitoneum

AXR large/small bowel dilatation, ileus, obstruction etc.

127
Q

Mx of aSx diverticular

A

high fibre

avoid NSAIDS/ opiates

128
Q

Mx of diverticular disease

A

paracetamol for pain
bulk forming laxatives
fluids + fibre

129
Q

Mx of diverticulitis

A

Broad-spec ABX (co-amoxiclav) for 7d, paracetamol, clear liquids 2-3 days

30% require surgery: sepsis, fistula, obstruction, perforation resection + colostomy

130
Q

what is merkels diverticulum

A

remnant of vitellointestinal duct @ distal ileum

131
Q

When could merkels be a DDx

A

Always consider in DDx of rectal bleed or intestinal obstruction

132
Q

Mx ischaemic bowel?

A

Resus O2, IV fluid

Papaverine relieve spasm, heparin for Mestenteric venous thrombosis

Surgical angioplasty to SMA

133
Q

What is chronic mesenteric ischemia often called? presentation?

A

Intestinal angina

Wt loss, postprandial pain, fear of eating

134
Q

Rfs for chorinic mesenteric ischemia

A

smoking, HTN, DM, hyperlipidaemia

135
Q

CMI ix

A

angiography is gold standard

FBC, LFT, UE for malnutrition and dehy

136
Q

mx od CMI

A

Nitrate therapy, anticoagulation

operate - bypass surgery

137
Q

3 causes of malabsorption

A

coeliac
chrons
cystic fibrosis

138
Q

Ix of malabsorption. Name 3

A

FBC, LFT, ESR, CRP

Iron studies (ferritin), folate, B12

Albumin and corrected calcium

Clotting screen + INR (vitamin K)

Anti-endomysial, anti-reticulin, alpha-gliadin
Faecal elastase (A1AT), microscopy and culture

AUSS gallbladder, liver, pancreas

Barium studies - structural

Ileocolonoscopy + biopsy

139
Q

Basic features of malabsoption of

Iron/fol/B12
Vit A
Vit D/Ca
Vit K

A

Pallor/glossitis

Hyperkeratosis/scaliness / night blondness

Osteomalacia / penia

Bleeding

140
Q

gene in coeliac

A

HLA-DQ2 (and DQ8)

141
Q

Histology coeliac

A

villous atrophy and crypt hyperplasia, increased intraepithelial lymphocytes, lymphocyte infiltration of LP

142
Q

Pres of coeliac

A

IBS, chronic fatigue

diarrhoea, wt loss, anaemia …… loads

143
Q

Skin features of coeliac

A

dermatitis herpetiformis: blistering at arms, legs, buttocks

144
Q

antibodies in coeliac

A

Tissue transglutaminase tTG IgA

Endomysial antibody EMA IgA

145
Q

3 parts of mx coeliac

1 Ix consider for comp

A

Lifelong strict gluten-free diet

prescription entitlement,
calcium/vitamin D supplements

Offer annual review: height and weight, symptoms

*Consider DEXA for osteoporosis (75% have low BMD due to affecting total bone mass reached as teen)

146
Q

What disease is similar to coeliac and can be differentiated by jejunal biopsy?

A

Tropical sprue - Jejunal biopsy - incomplete villous atrophy (Coeliac = total villous atrophy)

147
Q

mx of tropical sprue

A

Fluid replacement
Antibiotics - tetracycline 6-12 months
Nutritional support - folate, B12, iron (not with tetracyline - chelation)

148
Q

Initial sx / Red flags for gastric Ca

A

Vauge sx - dyspepsia, wt loss, dysphagia

ALARMS: anaemia, loss of wt, anorexia, recent onset, swallowing difficulty

149
Q

Which node indicates gastric ca

A

Virchow’s node (Troisier’s sign )

150
Q

Couple key Ix in gastric Ca

A

FBC (anaemia), LFT (to liver)
Flexible endoscopy/gastroscopy + biopsy

Sprial CT Abdo and thorax for mets

151
Q

mx of gastro Ca

A

Nutritional support/deficiency screen + symptom control (pain,nausea,const,dep)

SURGERY
Distal tumour - subtotal gastrectomy
Proximal - total gastrectomy

Perioperative chemo

152
Q

What is common mutation in Gastrointestinal stromal tumors

Mx?

A

80% have KIT receptor tyrosine kinase mutation

Complete surgical resection

Imatinib (tyrosine kinase inhibitor) - adjuvant

153
Q

What is a MALT lymphoma

A

mucosa-associated lymphoid tissue

Subtype of non-Hodgkin’s lymphoma

154
Q

usual association with malt tumours

A

H.pylori @ 90% gastric MALT

C.jejuni @ small bowel MALT

155
Q

Mx of early stage MALT

A

eradication of H.pylori - may cause complete remission in 70%

+ Endoscopic follow up

156
Q

Mx of advanced MALT

A

Eradication of h pylori

+ Rituxumab, + chemo + radi

surgery

157
Q

where are carcinoid tumours usually

A

70% of all are in the major bronchi (R side)

158
Q

What do carcinoid tumours secrete?

A

Vasoactive serotonin + bradykinin

159
Q

What effect does Vasoactive serotonin + bradykinin secretion have with carcinoid tumours

A

Bronchospasm, diarrhoea, skin flushing, R sided valvular lesions

160
Q

Ix in carcinoid tumour

A

Plasma chromogranin A (sensitive but not specific)

24 hr urinary 5-HIAA (>25mg = strong evidence)

Endoscopy or endoscopic ultrasound

CT/MRI

FBC, renal, UE, LFT, TFT, PTH, calcium, calcitonin, prolactin, aFP, CEA, b-HC

161
Q

What mx if surgical resection not possible in carcinoid tumour

A

somatostatin analogue e.g. *ocreotide which blocks 5-HT release,

radiotherapy and chemotherapy

162
Q

2 genetic causes of colorectal Ca

A

FAP - familial adenomatous polyposis - AD - mutation at APC gene 100% penetrance

HNPCC - hereditary non-polyposis colorectal cancer/ Lynch syndome, AD, 80% lifetime risk, defective DNA mismatch repair: colon, endometrial, ovary, stomach

163
Q

Ix in colorectal ca

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
Barium enema if colonoscopy fails

CT for mets (A/T/P) + liver USS

164
Q

Screening for colorectal

A

60 - 75, 2 yearly with FIT (faecal immunochemical test) then +ve for colonoscopy

165
Q

Why is IBS important

A

Significant negative impact on QoL and social functioning

For exams anyway

166
Q

Dx of IBS

A

6 month history of ABC (abdominal pain, bloating, change of bowel habit) +

Relieved by defecation or altered bowel frequency + 2 or more of
Mucus, worse on eating, abdominal bloating, altered passage (Straining, urgency)

167
Q

IBS Ix [think of DDx]

A 
FBC, ESR, CRP
Coeliac screen (EMA/TTG)
Ca-125 (ovarian cancer)
Faecal calprotectin (IBD)
± TFT, faecal occult blood, colonoscopy
168
Q

IBS Mx ?

diarrhoea?
constipation?
bloating?
abdo pain?

A

Lifestyle, dietary and physical activity
Decrease stress, relaxation, active physical activity, less caffeine, regular meals, fluids, decrease alcohol, high-fibre foods

Medications - placebo effect
Diarrhoea - loperamide
Bloating - peppermint oil
Constipation - laxatives e.g. ispaghula
Abdo pain - antispasmodics - buscopan (hyoscine butylbromide)
Psychological therapy
169
Q

UC vs Crohns
Rectal?
skip lesions? thickness?

A

ENDOCOPY + BIOPSY + BARIUM ENEMA

UC
goblet cell depletion, crypt abscesses, non-rectal sparing, continuous disease, ulcers, pseudopolyps
confined to mucosa and submucosa

C
granulomatous lesions, goblet cells, rectal sparing, skip lesions, mucus cobblestoning, transmural inflammation

170
Q

Non GI manifestations of crohns? name 3

A

Erythema nodosum, pyoderma gangrenosum, arthritis, iritis, conjunctivitis

171
Q

Key Pres of crohns

A

Diarrhoea (chronic >6W) ± blood
Abdominal pain
Weight loss
*periods of acute exacerbation

172
Q

Name 4 Ix in crohns

[Which for active disease monitoring?
Differentiate from IBS?]

A

FBC (all decreased), UE (renal disease as right ureter may be obstructed in ileocaecal disease), LFT (fatty liver)

ESR/CRP - high CRP -> active disease

Faecal calprotectin (IBS vs IBD)

Stool culture and microscopy

*Ileocolonoscopy + biopsy (UGI symptoms may require gastroduodenoscopy)

AXR (obstruction)

Malabsorption (iron, B12, folate, albumi

ASCA

173
Q

Crohns mx to induce remission? what if 2 or more exacerbations in 12 months ?

A

oral pred

add azathioprine or mercaptopurine (or methotrexate + folic acid)

174
Q

mx to maintain remission crohns

A

Monotherapy with azathioprine, mercaptopurine or methotrexate

Smoking cessation

175
Q

What do you always monitor in crohns

A

osteoperosis

176
Q

Ix UC. NAME 3

A

FBC (all decreased), UE, LFT (PSC)

ESR/CRP - high CRP -> active disease, ESR > 30

Faecal calprotectin (IBS vs IBD)

Stool culture and microscopy inc CMV and c.diff

Sigmoidoscopy + rectal biopsy (may be safer in severe disease to avoid perforation)

*First line: colonoscopy with multiple biopsies (x2 from 5 sites including distal ileum and rectum)

AXR (toxic megacolon)

Malabsorption (iron, B12, folate, albumin)

p-ANCA

177
Q

Induce remission
mild UC?

Acute/severe?

A

oral mesalazine
if no improvement in 4 weeks + oral prednisolone

Admit + IV hydrocortisone + IV fluids
Add IV ciclosporin if no response in 72 hours

178
Q

Maintain remission UC

A

oral mesalazine

179
Q

types of laxative and Eg

A

Bulk forming - increase faecal mass, stimulating peristalsis ispaghula husk

Stool softener - for impacted faeces: arachis oil enema

Stimulant - increase motility e.g. senna, docusate

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

180
Q

Which toxin can -> HUS

A

Shiga toxin

181
Q

Induce remission
mild UC?

Acute/severe?

A

oral mesalazine
if no improvement in 4 weeks + oral prednisolone

Admit + IV hydrocortisone + IV fluids
Add IV ciclosporin if no response in 72 hours

182
Q

Maintain remission UC

A

oral mesalazine

183
Q

types of laxative and Eg

A

Bulk forming - increase faecal mass, stimulating peristalsis ispaghula husk / Fybogel

Stool softener - for impacted faeces: arachis oil enema

Stimulant - increase motility e.g. senna, docusate

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

184
Q

Which toxin can -> HUS

A

Shiga toxin

[HUS is normally caused post E.Coli 157]

185
Q

Name 3 Xray signs of small bowel obstruction

A 
Central 
multiple bowel loops 
no gas in the large bowel 
Presence of ladders [lines across bowel loops]
Large bowel spared
186
Q

3 Xray signs of large bowel obstruction

A

1 big loop
peripherally
presence of haustrations
small bowel spared

187
Q

What is drip and suck?

A

NG tube to stop vomiting [suck]
NBM
IV fluids [drip]

[this is conservative Mx for small bowel obstruction]

188
Q

Blood pressure post AAA rupture aim

A

> 70 but not much more

189
Q

What is boars sign?

A

pain under right scapular in cholecystitis

190
Q

What do you have to check before using immunologic therapy for IBD

A

Tb as can cause latent -> active

[after immune supression ]

Phase 4 - GR (22 decks)

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