GI and Gensurg Flashcards
What are the non EtOH causes of chronic pancreatitis?
Cystic fibrosis Hereditary haemochromatosis Ductal obstruction
What are the complications of gastrectomy?
Dumping syndrome Weight loss Early satiety IDA Osteoporosis B12 deficiency Gallstones Gastric cancer
What is a good way to distinguish btween acute cholecystitis and biliary colic?
Patients with cholecystitis are typically systemically unwell
What is the most common cause of ascending cholangitis?
E coli
What is the typical presentation of a pancreatic pseudocyst?
Presents 6 weeks after an episode of acute pancreatitis Retrogastric fluid collection is seen Abdo pain, fullness
What is the best imaging technique to diagnose chronic pancreatitis?
CT pancreas with IV contrast
What might cause RUQ pain and jaundice in a post cholecystectomy patients 4 weeks post op having previously recovered?
Common bile duct stone
What electrolyte abnormality indicates severity of pancreatitis?
Hypocalcaemia
What investigation is useful in determining whether an isolated hyperbilirubinaemia is due to Gilbert’s syndrome?
FBC - would show signs of haemolysis
What is the management of acute cholecystitis?
Analgesia IV fluids IV Abx Lap Chole within 1 week of diagnosis
What respiratory pathology is a recognised complication of acute pancxreatitis?
ARDS
What is the management of choice in the case of an unresectable pancreatic carcinoma?
Palliative biliary stenting
What is the initial treatment of gastric MALT lymphoma?
H pylori eradication therapy
Blockages of which structures of the biliary tree does not cause jaundice?
Gallbladder Cystic duct
What condition is associated with pigmented gallstones?
Sickle cell disease (due to ghaemolysis)
In what part of the large bowel are diverticulae most commonly seen?
Sigmoid colon
What are the typical symptoms of diverticular disease?
Altered bowel habit Bleeding Abdo pain
What is the management of acute diverticulitis?
INcrease fibre intake Mild - abx Sev/recurrent - consider resection
60 year old man presents with IDA, what is the next step in his investigations?
Colonoscopy
What type of stoma do colostomies warrant, and what type are seen with ileostomies?
Colostomy - flush Ileostomy - spouted
What type of procedure is done for CRC at the: caecum, ascending or proximal transverse colon?
Right hemicolectomy
What type of procedure is done for CRC at the: distal transverse or descending colon?
Left hemicolectomy
What type of procedure is done for CRC at the: sigmoid colon?
High anterior resection
What type of procedure is done for CRC at the: upper rectum?
Anterior resection
What type of procedure is done for CRC at the: lower rectum?
Low anterior resection
What type of procedure is done for CRC at the: anal verge?
Abdomino-perineal resection
What is the management of a non-ruptured sigmoid volvulus?
1st - Decompression via rigid sigmoidoscopy and flatus tube insertion 2nd - Percutaneous colostomy tubing to decompress the volvulus
What is the typical presentation of a sigmoid volvulus?
An elderly man with chronic constipation and Parkinson’s disesae (on medication) with constipation, bloating, abdo pain and N/V
What are the risk factors for caecal volvulus?
Previous surgery IBD Adhesions Pregnancy
What are the referral guidelines for colorectal cancer?
Colonoscopy in: >=40 with wt loss and abdo pain >=50 w undexplained bleeding >=60 w IDA or change in bowel habit Urgent referral if: Rectal/abdo/anal mass <50 w bleeding and any of: pain change in bowel habit wt loss IDA
What tumour marker is used for CRC?
CEA
What is the current NHS colorectal cancer screening programme?
Individuals aged 60-74 undertake FOB testing every 2 years, and are offered colonoscopy if abnormal In addition, a one off flexi-sig is available at age 55 to detect and treat polyps
What procedure is offered for refractory anal fissures?
Sphincterotomy
What is a seton and when is it used?
A type of stitch used to promote healing of anal fistulae
What investigation should be used to confirm anastomosis has formed successfuly?
Gastrografin enema (less toxic than barium)
What is the nature of bleeding seen in haemorrhoids?
Post defecatory painless rectal bleeding noticed in pan and paper
What is the typical bleeding pattern of anal fissures?
Painflu rectal bleeding often with a sentinel skin tag
What is the difference between an anterior and posterior sited fissure?
Posterior are more common and are associated with the passage of hard stools Anterior fissures are typically linked to an underlying organic disease
What is the benefit of giving post op analgesia via an epidural over other methods?
It accelerates the return of normal bowel function
What is the single strongest risk factor for anal cancer?
HPV 16/18
What is typically found on DRE in haemorrhoids?
Nothing…!
What are anal fistulae typically secondary to, and what might they present with?
Ano-rectal sepsis Foul smelling discharge
What are some classical anorectal/bleeding features of UC?
Bright red blood mixed in with stool Diarrhoea Weight loss Nocturnal iuncontinence Mucous passage Proctitis
What is the typical presentation of solitary rectal ulcer syndrome?
History of IBS presents with bright red rectal bleeding - flexi sig shows fibromuscular obliteration
If a SCC is found in the anorectal region, where is it likely to have arisen from?
Anus Rectal cancers are very rarely SCC
What are the features of a gastric volvulus?
Borchardt’s triad: Vomiting Epigastric pain Failed attempts at NGT
What surgery? A 22-year-old man presents with his first presentation of ulcerative colitis. Despite aggressive medical management with steroids, azathioprine and infliximab his symptoms remain unchanged and he has developed a megacolon.
Sub total colectomy This is used over a panproctocolectomy, as patients with fulminant UC with rectal resection carry a very high risk of complications
What surgery? A 22-year-old lady has a long history of severe perianal Crohns disease with multiple fistulae. She is keen to avoid a stoma. However, she has progressive disease and multiple episodes of rectal bleeding. A colonoscopy shows rectal disease only and a small bowel study shows no involvement with Crohns.
Proctectomy Severe rectal Crohns that has developed complications such as haemorrhage and multiple fistulae is usually best managed with proctectomy. Although a diverting stoma may reduce the risk of local sepsis it is unlikely to reduce the bleeding. She is keen to conserve a rectum, however, an ileoanal pouch in this setting is unwise.
Roughly outline the Duke’s staging system
A - Confined to mucosa B - Invading bowel wall C - Lymph node mets D - Distant mets
Which heals better, loop ileostomy or loop colostomy?
Ileostomy
Are end stomas Reversible?
No
Where would you find a loop ileostomy and what is its role?
RIF - to defunction the colon following surgery
What is the role of an end ileostomy?
Usually following a panprotocolectomy
What is the role and siteof a loop colostomy?
May be anywhere in the abdomen depending on the colonic segment used Defunctions distal segment of colon
What patients typically get rectal prolapses, and how do they present?
Post partum women- presents with obstructed defectaion
A 72-year-old male has been diagnosed with rectal carcinoma. He is due to undergo a lower anterior resection. The aim of the resection is to restore intestinal continuity. Which is the most appropriate type of stoma?
Loop ileostomy This would defunction the large bowel giving time for formation of colo-anal anastamosis to heal
What should be done on discovery of a colovesicular fistula?
Abdo CT to look for other complications which may have occured
What investigation? A 72-year-old man is admitted with large bowel obstruction and CT scan suggests diverticular stricture in the sigmoid colon.
Laparotomy
What is the non-eponymous name for a Hartmann’s procedure?
Protosigmoidectomy
What is the management of a sigmoid volvulus with signs of peritonism?
Urgent laparotomy
What is the management of a mild diverticulitis flare?
Send home with oral Abx Advise to attend AnE if no improvement in 72 hours
What type of injury do patients in RTAs who incorrectly position their seatbelts get?
Carotid artery laceration
What are the blood film features of hyposplenism?
Howell Jolly bodies Pappenheimer cells Target cells
What are the ECG features of hyperkalaemia, and which is the most concerning?
Peaked T waves Flat P waves Broad QRS Sinusoidal wave pattern - pre-terminal
Side of lesion in tongue/uvular lateralisation?
Tongue goes Towards Uvula goes Uver way
What are the indications for splenectomy?
Uncontrollable splenic bleeding Hilar vascualr injury Devascularised spleen
When would you do a thoracotomy for haemathorax?
>1.5L initially OR >200ml/hour for >2 hours
What AXR finding is consistent with SBO, and how is this different to LBO?
In SBO you see valvulae conniventes which extend all the way across the bowel. In contrast, haustra seen in LBO only extend around 1/3 of the way across the bowel
Aside from GTN, what other agent may be used topically for anal fissures before consideration of sphincterotomy?
Diltiazem
What are the borders of the femoral canal?
Lateral - femoral vein Medial - lacunar ligament Anterior - inguinal ilgament Posterior - pectineal ligament
Where would you find a femoral hernia?
Inferolateral to the pubic tubercule
Are femoral herniae likely or unlikely to strangulate?
Likely - require urgent repair
What are the complications related to TPN?
Sepsis Refeeding syndrome Hepatic dysfunction (deranges LFTs)
How might an ilioinguinal nerve injury present?
Pain over the inguinal ligament which radiates to the lower abdomen and tenderness on compression of the inguinal canal
What is the presentation of femoral nerve injury?
Loss of hip flexion Loss of knee extension Loss of quadriceps tendon reflex Loss of anteromedial thigh sensation
What nerve is commonly damaged in carotid endarterectomy?
Hypoglossal
Aside from haemorrhagic shock, what type of shock may present following trauma, and how?
Spinal shock secondary to spinal cord transection which causes loss of sympathetic outflow resulting in hypotensive bradycardia with warm peripheries due to inadequate vasoconstriction
Rigler’s sign (double walling) indicating pneurmoperitoneum
What is the pathophysiology of a TRALI?
Acute noset non cardiogenic pulmonary oedema which occurs as a result of leucocyte antibodies in transfused plasma which cause aggregation and degranulation of host leukocytes in lung tissue -> pulmonary infiltrates
What are the vast majority of bladder cancers, and how do they present?
Transitional cell carcinoma presenting with painless haematuria
A 45-year-old woman presents with haematuria and loin pain. She has a temperature of 37 oC and is found to have a Hb 180 g/l and a creatinine of 156 umol/l. Her urine dipstick shows 3+ blood. Blood and urine cultures are negative.
Renal vein thrombosis secondary to renal cell carcinoma
How much fluid should be given to a burns patient weighing 80kg with 10% burns in the first 8 hours?
1.6L
10*80*4=3.2L in 24hours with half given in the first 8
A 30-year-old woman presents with pain and swelling of the left shoulder. There is a large radiolucent lesion in the head of the humerus extending to the subchondral plate.
Giant cell tumour - have ‘soap bubble appearance’ on X-ray, and typically present as pain or pathological fractures.
Which blood vessel is most commonly implicated in the rupture of a peptic ulcer?
Gastroduodenal - supplies the posterior aspect of the second part of the duodenum
Which shocks cause warm peripheries and which cause cool peripheries?
Warm: Neurogenic, septic, anaphylactic
Cool: Cardiogenic, spinal, hypovolaemic
What aer the features of a hepatic haemangioma?
Sommonly silent but may present due to mass effect
Hyperechoic on liver USS
What type of cancer does achalasia increase the risk of?
Squamous cell carcinoma of the oesophagus
What tumour marker is used for HCC?
AFP
Name 3 TNF alfa inhibitors and their uses
Adalimumab
Infliximab
Etanercept
Used in Crohns and Rheumatoid disease
What is the MOA of Trastuzumab and when would you use it?
HER receptor used in breast cancer
AKA- Herceptin
What is Basiliximab and when would you use it?
IL2 inhibitor used in renal transplant patients
What is a useful marker of disease recurrence in medullary thyroid cancer?
Serum calcitonin
What is a useful marker of disease recurrence in papillary thyroid cancer?
Thyroglobulin antibodies
What is a retractile testis?
A testis which appears only in warm conditions or can be brought down on clinical examination
A 68 year of man presents with recurrent episodes of left sided ureteric colic and haematuria. Investigations show some dilatation of the renal pelvis but the outline is irregular.
TCC - It is a urothelial cancer not just arising from the bladder
Which patient group is most commonly affected by spondylolisthesis?
Young athletic females with a background of spondylolysis
What is the classical feature of pseudomyxoma peritonei and where does it most commonly arise from?
Abundant mucin/gelatinous secretions, typiucally arising from the appendix
What is the anatomical definition of ‘upper GI’?
Proximal to the ligament of Treitz, the suspensory muscle of the duodenum at the duodenojejunal flexure
What should be done on detection of a congenital inguinal hernia?
Refer for surgery as they have a high rate of complications
What is a Richter’s hernia and how might it present?
A herniation of the antimesenteric border of the bowel ONLY herniates through an abdominal wall fascial defect.
It typically presents with symptoms of strangulation but NOT obstruction
What are the borders of Hesselbach’s triangle, and what does this mean for whether a hernia is direct or indirect?
Medial - Recus abdominis
Lateral - Inferior epigastric vessels
Inferior - Inguinal ligament
Herniae within the griangle are direct, and those outside are indirect
What is the annual risk of strangulation of a direct inguiunal hernia without surgery?
<5%
What is the best indication for a stable patient with an anal fistula?
Pelvic MRI to track the course and structure of the fistula
A 17-year-old male is admitted with lower abdominal discomfort. He has been suffering from intermittent right iliac fossa pain for the past few months. His past medical history includes a negative colonoscopy and gastroscopy for iron deficiency anaemia. The pain is worse after meals. Inflammatory markers are normal.
Meckel’s diverticulum - acid secretion causes bleeding and ulceration
