Gi Flashcards
ph findings in mesenteric ishaemia
- metabolic acidosis
when does mesenteric adenitis typically happen
- after URTI
3 types of mechanical intestinal obstruction
- luminal; gallstones, faeces, foreign body, meconium
- intra mural; strictures, intussusception
- extraluminal; hernia, adhesions, volvulus
different symptoms depending on small vs large bowel obstruction
Small; pain = high frequency colic, central vomit = early distention = late constipated = late
large bowel
- pain = low frequency colic, lower abdo
- vomit = late
- distention = early
- constipated = early
causes of paralytic intestinal obstruction
- sympathetic activity; reflex post op, rtroperitoneal bleed, malignancy
- bacteria
- biochem = k, urea, ca
- opiates, anticholinergics
- inflammation
what is considered dialtation in the small bowel
- > 3cm.
- valvulae coneventei all the way round
what is considered dilatation in large bowel
- 6cm +
- haustra not all the wat
what condition do you get the late sign of hiccups
- Peptic ulcer perforation
what glasgow blatchford score do you need to have a high chance of needing an intervention for UGI bleed
- 6+
what score predicts a high risk of death from UGI bleed in the rockall system
- > 8
if a patient has haematemesis due to UGI bleed, where most likely is the problem
- proximal to the duodenal jejunal flexure
what one Warfarin reversal agent do you not give in UGI bleed
- PCC, give FFP and plt instead if needed
what are the ALARMS symptoms
- anaemia
- loss of weight
- anorexia
- recent onset of progressive symptoms
- Malaena/ haematemesis
- Swallowing issues
how long before OGD must a patient nto eat
- 6hrs
what kind of cancer does barrets usually become-
invasive adenocarcinoma
define short vs logn barretts
- <3cm
- >3cm
surveillance guidance for baretts
no dysplasia - 2-5yrs
low grade; 6/12; biopsy every 1cm. radiofrequency ablation
high grade - 3/12. if visible lesion = endoscopic ablation with mucosal resection or radiofrequency ablation / oesophagectomy
typical sx Oesophageal ca
- dysphagia progress from solids to liquids
symptoms of diffuse oesophageal spasm
- intermittent dysphagia +/- chest pain
what is the mechanism behindd achalasia
- degeneration of myenteric plexus stopping the LES from relaxing
sx achalasia
- dysphagia
- regurg
- weight loss
rx achalasia
- endoscopic baloon dilatation
- hellers cardiomyotomy
then PPI
0r
Botox if no surgery
CCB and nitrates also relax sphincter
plummer vinson sydrome triad
- oesephageal webs
- IDA
- post cricoid dysphagia
which type of oesophageal ca is HPV a RF for
- squamous
what are you doing in a iv lewis oesophagectomy
- right sided thoractomy
- stomach into chest and oesophagus division mobilised
- anastamosis = intrathoracic oesophagogastric
what is zollinger ellison syndrome
- pancreatic or gastric gastrin secreting tumour
zollinger ellison syndrom sx
- abdo pain, dyspepsia, chornic diarrhoea and steatoorhea due to inactivation of pancreatic enzymes and damaged intestinal mucosa
zollinger ellison syndrom ix
- fastign gastrin level in serum . 3 x 3 days
- hypochlorhydria = reduced acid production will also cause increased gastrin production - ph will be <2
zollinger ellison syndrome rx
- high dose PPI
- surgery unless MEN1 = multiple adn mets #- somatosatin analogue and chemo
what type of ab is produced in h pylori
igg
screening test for h pylori and instructions
- urea breath test; stop abx 4 weeks before and PPis 2 weeks before
what does NICE recommend for gastric ulcers
all to biopsy as high malignant potential
rf gastric ca
- h pylori
- smoking
- alcholo
- diet high in nitrates
- EBV; diffuse type
- autoimmune gastritis
- e cadherin mutation = diffuse type. fhx
- FAP - intestinal type
two types of gastric adenoca
- diffuse = worse prognosis, young people. signet cells
- intestinal - old - better prognosis
where does gastric ca spread to
- Lymph
- lungs, liver, brain, ovaries via transcoelemic
rx gastric ca
- <5cm to OG jnct - total gastrectomy
- 5-10cm from jnct = sub total gastrctomy
+/- ESSMR
+ d2 NODAL RESECTION + chemo
name the 3 types of surgery that can be done for gastric ca
- bilroth 1
- bilroth 2
- roux en y
what is bilroth one surgery
- partial gastrectomy with simple anastamosis
what is bilroth 2 surgery
- partial gastrectomy wtih duodenal stump oversewn and anastamosis in jejunum
roux en y
- total or partial
- proximal duodenum oversewn
- proximal jejunum divided from distal
- proximal jejunum connects to oesophagus
- distal duodenum connects to jejunum
what is mirizzi syndrome
- compression of common bile duct by stone impacted in cystic duct
what can present similarly to jaundice
- hypercarotenaemial after prolonged and excess consumption of foods containing carotene
how to treat ascending cholangitis
ERCP
which anaesthetic can cause jaundice
- halothane
what liver problem is xanthelesmata a indication of
- primary biliary cirrhosis
what happens to colour of urine in hepatic jaundice
- darker as conjugated bilirubin is excreted by the kidney
what happens t o colour of urine and stools in post hepatic jaundice
- dark urine
- pale stool
common drugst that cause cholestatic jaundice
- fluclox
- steroids; cocp, anabolic
- sulfonylureas
- prochloperazin r
- chlorpromazine
where is hep a an endemic
- south america and africa
incubation period of hep a
2-6 weeks
what type of vaccine is available for hep a and who gets it
- inactivated = havrix monodose
- at risk; travellers tp endemic areas, close contacts, chronic liver disease, blood clotting disorders, MSM, IVDU, Occupational, HIV
hep b incubation period
- 1-6 months
what bone issue do patients with hep a and b get
- arthralgia
what does antihbs indicate
- previous immunisation or exposure
what does hbsag indicate
- current infection
what does anti hbcag indicate
- past infection
- sometimes current
what does hbeag indicate
- infectivity
complications of hep b infection
- chronic; ground glass hepatocytes on microscopy
- HCC
- cryoglobulinaemia
- polyarteritis nodosa
- glomerulonephritis
- fulminant liver failure
when are kids immunised for hep b
2,3,4 minths
what do the following anti-Hbs levels mean
post immunisation
- > 100
- 10-100
- <10
- adequate response, no more test. booster at 5yrs
- suboptimal response. 1 more dose. if immunocompetent then no further tests needed
- non responser. test for current or past infection. give course of 3 vaccinations and testing after.
rx hep b
- pegylated interferon 1st
- tenofovir 2nd
hep c incubation period
- 6-9 weeks
can you breastfeed if you have hep b/c
yes
hep c ix
- HCV RNA
hep c complications if chronic
- arthralgia, arthritis
- sjogrens
- HCC, Cirrhosis
- cryoglobulinaemia
- porphyria cutanea tarda esp with alcohol abuse
- membranoproliferative glomerulonephritis
what is porphyria cutanea tarda
- blistering skin on sun exposure
rx hep c acute
- support
rx hep c chronic
- test viral genotype
- protease inhibitor +/- ribavarin
ribavarin SE
- Cough, haemolytic anaemia. teratogen. cotnraception till 6 months after stopping
hep d ix and rx
= anti hdv if hbsag present
- INF alpha
what should babies born from hep c/b positive mums have
- full course vaccien + ig
2 types of autoimmune hepatitis
- 1 = 80%, young and middle aged. anti - SMA +ve, 10% ANA +Ve. IgG raised
- Type 2 - anti-LKM1 +ve . ana and asma -ve
kids and europe
rx autoimmune hepatitis
- prednisolone
- azathiprime for maintenance from remission usually in 2-3 yrs
- transplant
what is the classification system for encephalopathy
- west haven
west haven classificaiton of encephalopathy grades
- sleep reversasl, lack of awareness, short attention span, impaired computations
- lethargy, memory impaired, personality change, asterixis
- somnolence, confused, disorientated. hyper-reflexia, nystagmuus, clonus, rigidity
- stupor/ coma
rx encephalopathy
lacutlose
rifaximin as prophylaxis
indicators of poor prognosis in acute liver failure that is paracetemol induced
- ph 7.3 or
- INR >6.5/ PT >100seconds
- grade 3/4 encephalopathy
- creat >300
- lactate >£
indicators of poor prognosis in acute liver failure that is NOT paracetemol induced (also kings college criteria for transplant)
- Ph <7.3 post volume resus
- PT >100 s
or 3 of beloow - PT >50 (INR >3.5) - Bili >300 - jaundice to enceph >7/7 - age <10/ >40 - etiology; NANB (non hep a , non hep b) or drug induced
if acute liver failure and hepatic encephalopathy + cerebral oedema - RX
- Mannitol
- hyperventilate
5 stages of cirrhosis
- no varices
- varces
decompensated
- bleed
- ascites
- ascites bleeding
what metabolic issues canc ause decompensated liver failure
- hypokalaemia as causes ammonia to build up and cross BBB
- metabolic alkalosis
- increased protein intake = more ammonia
- constipation - prolonged exposure of GI content
RF for Alcoholic liver disease
- alcohol
- hep c
- female
- obese
what happens to plt in liver disease
- goes down due to splenic sequestration
what happens to na in liver disease
- down in cirrhosis
what happens to ast:alt ratio in cirrhosis
- > 1
what scoring system predicts prognosis in chronic liver disease
- child pugh
what is the minimum score on UKELD to be added to transplant list for liver
- 49
transudate causes of ascite s= low protein
- cardiac failure
- liver failure
- nephrotic syndrome
- myxoedema
exudate causes of ascites = high protein
- cirrhosis
- abdo malignancy
- pancreatitis
- infection/ TB/perforation
- lymphatic obstruction
ix for someone with ascites
- FBC, = infection
- u and e = renal failure
- LFT
- CLotting
- TFT
- hepatitis screen
- amylase
- USS/CT
- Ascitic tap + mc&s, cytology and biochem
rx ascitic liver disease-
salt restrict
- spironolactone 1st line
- furosemide 2nd
- paracentesis + fluid replace
- TIPS
what does alt>ast indicate in terms of NASH/NAFLD
-NASH
what does steatosis mean
- fat in the liver
what does steatohepatitis mean
- fat with inflammation –> NASH
ix for NAFLD
- If incidental found on liver uss –> enhanced liver fibrosis blood test. if unavailable fib4 score and fibroscan
- liver biopsy for staging
most common type of pancreatic cancer
- adenocarcinoma
rf pancreatic cancer
= smoking
what is the only curative surgery in pancreatic ca
- whipples procedure
- remove distal stomach, gallbladder, common bile duct, head of pancreas,e duodenum, proximal jejunum and regional LN
rare features of pancreatic ca
- thrombophlebitis migricans = arm vein swells thena leg one
- high ca
- endocarditis
- portal HTN = splenic vein thrombosis
- nephrosis. renal vein mets
sx of body of pancreas ca
- back pain
- steatorrhoea
- weight loss
- anorexia
- abdo pain relieved by sitting forward
sx of tail of the pancrease ca
- late presentation with mets, malignant ascites or unexplained anaemia
define acute diarrhoea
- <14 days
define chronic diarrhoea
- > 30 days
4 types of diarrhoea
- osmotic
- secretory
- infectious.infla
- deranged motility
What happens in osmotic diarrhoea
- food is staying in intestine so drawing more water in
what causes secretoroy diarrhoea
- cholera
- laxatives
- hormones from tumours
extra intestinal manifestations of UC
- Ank spond
- osteoporosis
- osteopenia
- uveitis
- episcleritis
- conjunctivitis
- erythema nodosum
- pyoderma gangrenosum
crypt abscesses are a typical feature of which type of IBD
- UC
classify severity of UC
- Mild = <4 stools passed, only little blood
- moderate 4-6 stools, moderate varied amount of blood, no systemic upset
- severe - >6 bloody stools pr day + systemic upset
UC treatment
induce remission;
mild/moderate - topical salicylate
- no improvement in 4/52 –> oral ASA, then if doesnt work then oral steroids
severe –> IV steroids/ ciclosporin if steroid CI
maintain
- mild/mod and proctitis = topical asa or topical and oral asa
- mild/mode and left sided or extensive = oral ASA
severe or more than 2+ relapses in a year = azathioprine
rx crohns disease
induce; steroids or budesonide if CI
+/- enteral feed
5-ASA 2nd line
maintain - stop smoking azathiprine/ mercapto - 2nd = methotrexate - 3rd - ASA
surgery;
ileocaecal resection
right hemicolectomy
hartmanns
I and D with seton
UC surgery options
- total coelectomy with
- ileo anal anastamosis
- ileall pouch
- end ileostomy
- sub total colectomy
what nutritional deficiency do patients with crohsn often have
- b12 and folate
p ANCA is more often found in which type of IBD
- UC
determining severeity of UC is classified by which system
- true love and whitts criteria
thumb printing, lead pipe and toxic megacolon are common in which type of IBD
- UC
apple core strictures are seen in which type of IBD
- Crohns
contraindications to liver biopsy patients
- uncooperative patient
- bacterial cholangitis
- coagulopathy
what size liver HCC can be resected
- <5cm
- or up to 3 lesions <3cm
what cells are affected in carcinoid syndrome
- enterochromaffin
what are cardiac complications of carcinoid syndrome
- pulmonary stenosis
- tricuspid incompetence
ix and rx carcinoid syndrome
- High 5-IHIAA in urine
rx
- somatostatin analogue
cholangiocarcinoma causes
- flukes
- primary sclerosing cholangitis, hep
cholangiocarcinoma rx
- major hepatectomy + extrahepatic bile duct excision + caudate lobe resection.
- post op comp = bile leak, liver failure and obstructed extrahepatic biliary tree - fix with ERCP
liver adenomas are associated with what rf
- cocp
- anabolic steroids
when to treat liver adenoma and how
- if sympto or >5cm
- stop cocp
- resect
abx for amoebic liver abscess
- metronidazole
what liver issue can cause a pleural effusion in the right lower zone
- liver abscess
what bone issue does hereditary haemochromatosis cause
- chondrocalcinosis
incubation period noro
- 24-48hrs
incubation period of staph and abcillus
- 1-6hrs
incubation period of salmonella and ecoli
12-48hrs
incubation period shigella and campylobacter
- 48-72hrs
incubation period giardiasis and amoeibasis
- > 7/7
ix gastroperesis
- scintigraphy - >10% retention after 4hrs of meal
rx gastroperesis
- prokinetic e.g. metoclopramide
- antidepressant
IBS diagnostic criteria`
- recurrent abdo pain at least 3 days/month for 3months with 2 or more of the following
- relief on defecation
- onset assocaited with change in frequency of stool
- onset associated with change in form/áppearance of stool
which types of polyps are higher risk of colon cancer
= villous
what is the mechanism of cancer in FAP-
- germline mutation in APC gene - chromosome instability pathway.
inheritance pattern of FAP
- AD
Why do we do prophylactic panproctocolectomy in FAP patients
- 100% get colon adenocarcinoma by 40. have many polyps and every single cell in body already has mutation so only needs one more hit for cancer.
cancers more common in FAP-
- Colorectal; small intestine
- gastric cancer
- desmoid tumours
- thyroid cancers
- osteomas
- RPE congenital hyeprtrophy
lynch syndrome MOA and inheritance pattern
- microsatellite instability pathway; mismatch repair genes mutations - one allele of MSH6, MSH2, MLH1, PMS2
cancers more common in lynch syndrome
colorectal
- endometrial
- stomach
- pancreas
- small bowel
- ureter
- renal pelvis
- ovarian cancer
what side of colon to lynch syndrome cancers appear
- right side
what is constipation defined as
- <2 motion/week
- less than normal
- difficult/ incomplete evacuation
what metabolic abnormalities can cause constipation
- hyperca
- hypothyroid
- hypok
- porphyria
- lead poisoning
- T2DM
what common drugs given in HTN cause constipation-
CCB
Diuretics
other name for lynch syndrome
- HNPCC
dukes criteria staging
A = mucosa, submucosa +/- muscularis propria
B = subserosa and beyond
C = Any with LN involved
D = distant mets
what surgery do you do for rectal tumours
- anterior resection
= remove all rectum with primary anastamosis - abdomino perineal resection = if tumour low in rectum <8cm from anus = remove rectum and anus and permanent colostomy
- total mesorectal excision
all surgical resections of colon require hwo many cm clearance
5cm
which side of colon are hyperplastic polyps usually seen?
what about sessile?
left
right
what do alpha cells in pancreas make
- glucagon
what do delta cells in the pancreas make
- somatostatin - supresses release of gastric hormones so decreased rate of gastric emptying
why does calcium rise cause pancreatitis
- activates conversion of trypsinogen to trypsin –> autodigestion
complications of acute pancreatitis
- shock
- aki
- ards
- DIC
- Sepsis
modified glasgow criteria for pancreatitis
Pao2 <8 Age >55 N = WCC>15 C = calcium <2 Renal= urea >16 Enzymes = LDH >600/ AST>200 A = albumin <32 S= sugar >10
1 point if any criteria in first 48h. 3+ = ITU
rx acute pancreatitis
- fluid resus
- ng tube to decompress
- analgesia - not morphine if possible
- antiemetic
- sort glucose
- vitals
- ERCP if gallstones
what skin issue can you get in chronic pancreatitis
- erythem ab igne
what type of DM does chronic pacnratitis cause
- type 3c; disease of exocrine pancreas
cause of acute mesenteric ischaemia
- embolus, thrombus, non occlusive ischaemia
cause of chronic mesenteric ischaemia
- atherosclerosis of all 3 vessels supplying the gut
sx acute mesenteric ischeamie
- abdo pain
- no abdo sign
- shock
sx chronic mesenteric ischaemia
- severe colicky post prandial pain = gut claudication
- pr bleed
- weight loss
- feaer of food
- malabsoprtion
- fatigue
- abdo bruits
- abdo tender
sx chronic large bowel ischaemia
- bloody diarrhoea
- left sided abdo pain
- fever
- tachy
- PR blood
what is the colalteral blood supply to the colon
- marginal artery of drummond
watershed zones in the colon vulnerable to mesenteric ischaemia
- right colon as artery of drummon not well developed here.
- splenic flexure as tenuous or missing artery of drummond
- rectosigmoid junction as distal to last collateral of proximal arteries that supply colon
most common organ involved in stabbings
- liver
organ most commonly involved in gunshot wounds
small bowel
indications for resus laparotomy in abdo trauma
- life threatening blunt trauma
- unresponsive hypotension despite resus with no other cause of bleeding found
indications for urgent laparotomy in abdo trauma
- blunt trauma with positive lavage or free blood on USS with unstable circulation
- peritonitic
- kinfe injury associated with visible viscera, peritonitis, haemodynamic instability or sepsis
- gunshot wound
what is choledocholithasis
- gallstone obstruct common bile duct
what is gallstone ileus
- obstruction of small bowel by gall stone via fistula. the obstruction causes vigorous peristalsis = gallstone ileus (different to what ileus normally means)
in which gallstone related disease would you do a U and E and G and s as well as clotting and ABG
- ascending cholangitis
who are spigelian hernias most commonly seen in, and what are they called
- older pts
- lateral ventral; hernia through spigelian fascia (the aponeurosis between the rectus abdominas medially annd the semilunar line laterally
what is a richters hernia
- only antimesenteric border of the bowel herniates through the fascial defect
congenital inguinal hernias are more common on which side
- right
where are inguinal hernias in relation to the pubic tubercle
- medial and above
direct vs indirect hernia relationship to inferior epigastric artery
- medial = direct
- lateral = indirect
direct hernia rx
- open mesh/ lap
- wait and watch
indirect hernia rx
- kids = herniotomy, adults = open mesh/lap
- wait and warch
inarcerated femoral hernia operation
= iguinal approach
if not incarcerated and not small bowel involved can do infrainguinal
where do femoral hernias lie in relation to femoral vein
- medial
how to treat incisional hernias
- <4cm = simple sutures
- > 4cm = place mesh between posterior rectus sheath and rectus abdominis
- lap approach
what is zenkers divcerticulum
- pharyngoesophageal false diverticulum. oesophageal dysmotility = herniation of mucosa at killians triangle b/ween thyro and cricopharyngeal constrictor
sx of zenkers diverticulum
- dysphagia
- obstruction
- gargling
- halitosis
- neck mass
- aspiration
zenkers diverticulum mnemonic
- elder mike has bad breath
- elderly people
- killian triangle
- halitosis
- oesophageal dymsotility
what are the rule of 2s for meckels diverticulum
- 2 times more common in men
- 2 inches long
- 2ft from IC valve
- 2% population
- common presents in first 2yrs of life
- 2 types of epithelia; gastric/pancratic
staging for surgery or not in diverticular disease (hinchey classification)
stage 0 = no abscess
stage 1; pericolic or mesenteric abscess
= no surgery - radiological drain
2 = walled off or pevic abscess = sometimes surgery - lap washout/radio drain
3= generalised purulent peritonitis = surgery - wash out/ hartmanns
4= generalised faecal peritonitis = surgery - hartmanns
pus somewhere pus nowhere in context of asbcess means…
- pus under diaphragm
what abx do we most commonly give in acute diverticulitis
- cipro
- metro
where do far eastern people get diverticulitis
- right side
appendicitis GS dx
- CT
what is the scoring system used in appendicitis
- alvadaro score >7 = appendicitis
- <5 - unlikely
- RIF tenderness 2
- rebound tenderness 1
- rif migratory pain 1
- anorexia 1
- n and v 1
- fevver 1
- leukocytosis 2
- left shift neutrophils 1
what incision is used in open appindectomy
- grid iron
why do you never make a lateral incision at mcburneys point in appindectomy
- can cut ileohypogastric nerve
main RF for cholangiocarcinoma
- Primary sclerosing cholangitis
- liver flukes
- typhoid
anal cushion positions
- 3,7, 11 oclock
where does lymph drainage above the pectinate line occur
- below?
- pelvic
- inguinal
classification of haemorrhoids
- remains in rectum
- prolapses through anus on defecation but reduces spontaneously
- protrudes throught anus but needs digital reduction
- remain persistently prolapsed
OR INTERNAL VS external - pectinate line seperates
surgical rx for haemorrhoids and there associated side effects
- band ligation - banding = ulcer tethering mucosa. SE = Bleed, pain, infection
- sclerotherapy; SE = Impotence, prostatitis
- infra red photocoag
- surgical removal in grade 4 and where other options failed. SE - Haemorrhage and stenosis. 2 weeks off work needed.
anal fissure rx
- conservative
- lidocaine for topical pain relief
- GTN ointment
- diltiazem
- botox
- lateral sphincterotomy
what is goodsalls law for fistula in ano
- anterior fistula = vertical drain
- posterior drain at 6o clock
anal abscess classification
- intersphincteric = in between internal and externals phoncter
- perirectal = ischiorectal psace
- supralevator = above anorectal ring
parks classification of anal fistulas
- intersphincteric
- transphincteric ; through external sphincter
- suprasphoncter - ascends from intersphinceteric space to puborectalis then levator ani
- extrasphinceric - outside external sphinc
fistula rx
- fistulotomy and excise
- seton suture esp if high fistula where excising = incontinence
what kind of cancer is anal ca most commonly
- SCC
what type of anal cancer has worse prognosis
- above pectinate line is worse
rx anal ca
- chemo and radio = preferred
- AP resection if failed after 6 weeks of CHRT
rx rectal prolapse
- manual reduction
or if persists - abdo approach = rectopexy +/- mesh +/- rectosigmoidoscopy
- perineal approach - delornes procedure = resect close to dentate and sutture muscosal boundries
causes of b1 defi and sx
- alcoholics or white rice diet
- polyneuropathy, HF, Wernickes
causes of B2 def
- decreased milk or chronic malabsoprtion
B3 deficiency causes
- Dermatitis
- diarrhoea
- dementia
- -> v photosensitive
sx vit c deficiency
- gingivitis, petechiae, rash, internal bleeds, impaired wound healing
- need for bone and bvs
rx for morbid obesity
conservative
medical ; orlistat if BMI >30 or >28 + RF. Max 1 yr use
surgical if BMI >40 OR 35+ with comorbidities and failure of diet measures
- gastric banding
- bypass
- sleeve gastrectomy; remove part of stomach
- intra gastric ballooon – filled with air or salt water then passed downt throat
- biliopancratic diversion
