Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

FINALS > GI and Liver > Flashcards

GI and Liver Flashcards

1
Q

What should patients with coeliac receive every 5 years?

A

PCV vaccine due to hyposplenism

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What should patients with spontaneous bacterial peritonitis receive?

A

Abx prophylaxis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Patients with raised platelets and nausea need what?

A

Non urgent referral for endoscopy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Management of patient with suspected upper GI bleed?

A

endoscopy within 24 hours of admission

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the treatment of wilsons?

A

Penicillamine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Sudden onset severe abdo pain with vomiting and rapid bloody diarrhoea?

A

Acute mesenteric ischaemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Raised transferrin and ferritin with low TIBC suggests what?

A

Haemochromatosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Sudden onset abdo pain in someone with peptic ulcer disease?

A

Perforated peptic ulcer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

How are perforated peptic ulcers managed?

A
  • Erect CXR which shows free air under diaphragm
  • Refer to general surgery
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Tx of C diff?

A
  • Oral vancomycin for 10 days
  • If reoccurs: oral fidaxomicin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Anti-mitochondrial antibodies suggest what?

A

Primary Biliary Cholangitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

First line medication for PBC?

A

Ursodeoxycholic acid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is associated with UC?

A

Primary sclerosing cholangitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Investigation of choice for suspected pancreatic cancer?

A

High resolution CT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Management of liver abscess?

A

Percutaneous drainage with IV Abx - usually amoxicillin, ciprofloxacin and metronidazole

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Vomiting followed by severe chest pain and signs of shock?

A

Oesophageal rupture (Boerhaave syndrome)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What cancer is associated with PSC patients?

A

Cholangiocarcinoma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What does pernicious anaemia predispose to?

A

Gastric carcinoma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Management of C diff if symptoms still ongoing after 10 days?

A

Oral vancomycin and IV Metronidazole

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What should be measured to monitor treatment of haemachromatosis?

A

Transferrin saturation and serum ferritin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Management of haemachromatosis?

A
  • Venesection
  • Desferrioxamine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What should be given to patients with suspected variceal bleeding before endoscopy?

A

Terlipressin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Coeliac disease increased risk of which cancer?

A

enteropathy associated T cell lymphoma of small intestine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Diarrhoea with greasy stools in swimming pool user?

A

Giardia lamblia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
What is SAAG (serum ascites-albumin gradient) used to measure?
- Portal HTN - If >11, then portal HTN
26
How is dyspepsia managed?
- Trial of PPI for 1 month OR test and treatH pylori - If either is unsuccessful, try the other approach
27
What are patients with haemochromatosis at risk of?
Hepatocellular carcinoma -> screening with US needed
28
sweet and fecal breath is indicative of what?
Liver failure
29
When should PPIs be stopped before upper GI endoscopy?
2 weeks before
30
Which artery is most likely to be the source of bleeding for someone with peptic ulcer disease?
Gastroduoedenal artery
31
Tenesmus is generally associated with which IBD?
Ulcerative Colitis
32
Crohn's Disease
N – No blood or mucus (PR bleeding is less common) E – Entire gastrointestinal tract affected (from mouth to anus) S – “Skip lesions” on endoscopy T – Terminal ileum most affected and Transmural (full thickness) inflammation S – Smoking is a risk factor Other - Terminal ileum - Ulcer, cobblestone appearance - Non-caseating granulomas
33
Ulcerative Colitis
C – Continuous inflammation L – Limited to the colon and rectum O – Only superficial mucosa affected S – Smoking may be protective (ulcerative colitis is less common in smokers) E – Excrete blood and mucus U – Use aminosalicylates P – Primary sclerosing cholangitis
34
What is the histology of UC?
- Large bowel - Mucosal involvement only - Crypt abscess, reduced goblet cells and no granulomas - Continuous inflammation - Pseudo polyps and ulcers may form
35
What is the histology of Crohns?
- Entire GI tract affected - Transmural inflammation - Non-caseating granulomas - Discontinuous inflammation (skip lesions) - Cobblestone appearance: fissures and deep ulcers - Fistula formation
36
Diarrhoea, fatigue, osteomalacia?
Coeliac disease
37
What is carcinoid syndrome?
A condition usually when metastases are in the liver and then release serotonin into circulation
38
How does carcinoid syndrome present?
- Flushing - Diarrhoea - Bronchospasm - Hypotension - urinary 5-HIAA should be measured with ocreotide to treat
39
What is a key intervention in patients with asictes?
Restrict dietary sodium
40
Management of Barret's?
High dose PPI + endoscopic surveillance
41
What should be avoided in patients with severe colitis?
Endoscopy -> risk of perforation -> use flexible sigmoidoscopy instead
42
What are the red flags for GI cancer?
new-onset dyspepsia in a patient aged >55 years unexplained persistent vomiting unexplained weight-loss progressively worsening dysphagia/ odynophagia epigastric pain
43
fatigue, erectile dysfunction and arthralgia?
Haemochromatosis
44
How can haemochromatosis present?
- Bronze skin - Diabetes - Liver disease - Cardiac failure secondary to dilated cardiomyopathy - Arthritis
45
signet ring cells are indicative of?
Gastric adenocarcinoma
46
How does achalasia present?
- Dysphagia of liquids and solids - Heartburn - Regurgitation of food
47
How is achalasia investigated?
- Gold standard: Oesophageal manometry which shows excessive lower oesophageal sphincter tone - Barium swallow shows bird's beak appearance
48
How is achalasia managed?
- Pneumatic balloon dilation - Surgical intervention: Heller cardiomyotomy
49
What sign may be seen in pancreatic cancer?
Double duct sign -> dilated common bile duct and dilated pancreatic duct
50
What does Riglers sign indicate?
- Gas in the peritoneal cavity: sign of perforation
51
How should gallstones be managed?
If asymptomatic and in the gallbladder, no treatment needed If in the common bile duct, surgery should be considered If symptomatic, surgery
52
What is acute mesenteric ischaemia?
Occlusion of an artery supplying the small bowel, usually superior mesenteric artery History of AF is common Sudden-onset, severe pain with normal examination
53
How does acute mesenteric ischaemic be managed?
- Test serum lactate which will be raised - Urgent surgery needed: immediate laporotomy
54
Severe abdo pain, sudden onset and out-of-keeping with exam findings?
Acute mesenteric ischaemia
55
What is ischaemic colitis?
Occlusion of blood flow to the large bowel resulting in inflammation, ulceration and haemorrhage. Acute but transient.
56
Where is ischaemic colitis most likely to occur?
Splenic flexure. (watershed areas such as splenic flexure located at borders of the territory supplied by superior and inferior mesenteric arteries.
57
How will ischaemic colitis be managed?
Abdo X ray - thumbprinting seen Supportive treatment, surgery if severe
58
Indications for surgery in ischaemic colitis?
- generalised peritonitis - perforation - ongoing haemorrhage
59
Ix for ischaemic colitis?
abdo x-ray= 'thumbprinting' due to mucosal oedema/haemorrhage
60
How should a severe flare of UC be treated?
IV corticosteroids
61
Iron defiency anaemia vs. anaemia of chronic disease
TIBC is high in iron deficiency but low/normal in chronic disease Think of TIBC as the amount of space in the body to store iron: this will be high in iron deficiency as no iron
62
What should be given alongside isoniazid to prevent peripheral neuropathy?
Pyridoxine (vitamin B6)
63
T2DM with abnormal LFTs
NAFLD
64
What blood test can be done alongside incidental findings of NAFLD?
Enhanced liver fibrosis test
65
Which drugs are used to maintain remission in Crohns?
Azathioprine or mercaptopurine
66
Mild vs Moderate vs Severe flares of UC
Mild - <4 stools daily with no systemic disturbance Moderate - 4-6 stools per day with minimal systemic disturbance Severe - >6 stools per day with systemic disturbance
67
What is a severe complication of IBD flare up?
Toxic megacolon -> abdo X-ray needed
68
Which scores are used in acute GI bleeds?
1. Glasgow Blatchford score to identify who can be managed as outpatient 2. Rockall score done after endoscopy to identify risk of rebleeding
69
Alcohol units formula?
volume (ml) * ABV / 1,000
70
What can be given as prophylaxis for episodes of hepatic encephalopathy?
Lactulose
71
Metabolic alkalosis + hypokalaemia
Vomiting
72
Which tool is used to assess for malnutrition in patients?
MUST - malnutrition universal screening tool
73
What is small bowel bacterial overgrowth syndrome?
- Excessive bacteria in the small bowel - Diabetes and Scleroderma are associated with this - Presents like IBS: abdo pain, diarrhoea, bloating - Hydrogen breath test to diagnose - Abx usually rifaximin used to treat alongside correcting cause
74
severe, colicky post-prandial abdominal pain, weight loss, and an abdominal bruit
Intestinal angina/chronic mesenteric ischaemia
75
'intestinal angina', colickly, intermittent abdo pain with non-specific features?
chronic mesenteric ischaemia (rare clinical diagnosis)
76
What is alcoholic ketoacidosis?
- Euglycaemic ketoacidosis seen in those who drink alcohol excess - Presents with metabolic acidosis, elevated ketones but NORMAL/LOW glucose levels - Tx with IV fluids and thiamine
77
Which test should be used to test for eradication of H pylori?
Urea breath test
78
What is the most common cause of inherited colorectal cancer?
HNPCC - hereditary nonpolyposis colorectal cancer
79
What are aminosalicylates associated with?
Agranulocytosis - check FBC
80
Pain on swallowing (odynophagia) can be a sign of what?
Oesophageal candida
81
What is used to determine the severity of the C diff infection?
WCC
82
Bleeding gums and receding
Scurvy
83
liver and neurological disease
Wilsons disease
84
Electrolyte imbalances of refeeding syndrome ?
Hypophosphataemia, hypokalaemia and hypomagnesaemia
85
Abdominal pain, Bloating and Change in bowel habit
IBS
86
Cholestasis vs liver damage on bloods?
Liver injury - >10 times increase in ALT and <3 times increase in ALP Cholestasis - <10 times increase in ALT and >3 times increase in ALP
87
Which drugs can cause cholestasis?
- COCP - Abx including flucloxacillin, co-amoxiclav
88
Coeliac disease is associated with deficiency of what?
iron, folate and vitamin B12 deficiency
89
Which IBD is associated with gallstones?
Crohns
90
What is used to assess whether glucocorticoid therapy may be beneficial in alcoholic hepatitis?
Maddreys function - serum bilirubin and prothrombin time
91
Antinuclear antibodies, anti-smooth muscle antibodies and raised IgG levels
Autoimmune hepatitis
92
dysphagia, glossitis and iron-deficiency anaemia
Plummer-Vinson syndrome
93
watery green diarrhoea post cholecystectomy
Bile acid malabsorption -> treat with cholestyramine
94
What is decreased in Wilsons disease?
serum caeruloplasmin
95
Haemochromatosis is a cause of what?
Hypogonadotropic hypogonadism
96
Patients with a suspected GI bleed require what?
OGD within 24 hours
97
What LFTs can indicate pancreatic cancer?
Cholestatic picture
98
What is an unreliable indicator of iron stored in the body during illness?
Ferritin -> use transferrin saturation instead
99
What can be used to differentiate between and upper and lower GI bleed?
Urea levels - high in upper GI bleed
100
Investigations for PSC?
1. US scan 2. MRCP
101
What is used for prophylaxis of oesophageal bleeding?
Propranolol
102
Management of severe alcoholic hepatitis?
Steroids
103
Which cancers are associated with HNPCC?
- Colorectal - Endometrial - Ovarian - Pancreatic
104
What is the treatment of hypophosphatemia?
Intravenous infusion of phosphate polyfusor
105
Most common organism causing SBP?
Gram negs - E coli, Klebsiella
106
Management of Dysplasia on biopsy in Barrett's oesophagus
Endoscopic intervention
107
What should you test to screen for haemochromatosis?
Transferrin saturation
108
Psychosis is a complication of what?
Wilsons disease
109
What is the investigation of choice for perianal fistulae in Crohns?
MRI
110
Bleeding vs perforated peptic ulcer?
Perforated ulcer should present with signs of peritonitis e.g. abdo pain, distension, guarding
111
Deranged LFTs and AKI in someone with septic shock?
Think ischaemic hepatitis
112
Patients allergic to aspirin may also react with what?
Sulfasalazine
113
What is Richter's hernia?
A rare hernia which causes a firm, erythematous mass -> often presents with symptoms of strangulation (ischaemia/necrosis over the skin)
114
What should be given for prophylaxis of variceal bleeds?
Propranolol
115
Management of SBP
Acute: IV Cefotaxime Abx prophylaxis if they have ascites: Ciprofloxacin until ascites resolves
116
Back pain worse on lying down, appetite loss and weight loss
Pancreatic cancer
117
What is the most common type of oesophageal malignancy in patients with GORD?
Adenocarcinoma
118
What can cause a wheeze in people with GORD?
Inhalation of small amounts of gastric contents
119
What is the gold standard investigation for GORD?
Oesophageal pH manometry
120
What surgery can be done for GORD and what does this do?
Nissen fundoplication - fundus wrapped around the abdo oesophagus to improve strength of the gastro-oesophageal junction
121
What is a complication of Nissen fundoplication?
Dysphagia from compression of the junction
122
Examination signs of chronic liver disease
- Clubbing - Palmar erythema - Dupuytren's contracture - Hepatosplenomegaly - Ascites
123
What are complications of liver cirrhosis?
- Encephalopathy - Sepsis - SBP - Ascites - Varices
124
What dietary advice would you give someone with ascites?
- Fluid restriction - Low sodium
125
Why is lactulose given in encephalopathy?
Reduce number of nitrogen producing bacteria in the gut which contribute to hepatic encephalopathy
126
Why can anti-EMA antibodies be negative in severe malabsorption in coeliac?
Deficiency in proteins such as IgA
127
Haematemesis + distended abdomen
Variceal bleeding
128
What is an indicator of pancreatitis severity?
Hypocalcaemia
129
What is the most common cause of large bowel obstruction?
Tumour then volvulus/diverticular disease
130
What do Hepatitis B serology markers mean?
HBSAg - acute infection (if > 6 months then chronic infection) Anti-HBs - immunity Anti-HBc - previous/current infeection
131
Causes of different types of jaundice
Pre - Sickle cell, G6PD, Hereditary spherocytosis Hepatic - Hepatitis, PBC, PSC, EPV, HCC Post hepatic - biliary atresia, gallstones, pancreatitis
132
Stages of liver disease
Steatosis -> Fibrosis/Steatohepatitis -> Cirrhosis
133
When is liver transplant indicated in liver disease?
In chronic liver disease, patients must have stopped alcohol for atleast 6 months
134
What are complications of GORD?
- Barret's - Adenocarcinoma - Oesophageal stricture - Chronic cough
135
What are complications of UC?
- Colon cancer - Toxic megacolon - Bowel perforation
136
Where does volvulus cause large bowel obstruction?
Sigmoid
137
What is coffee bean sign indication of?
Sigmoid volvulus
138
What is the management of sigmoid volvulus?
Stable - rigid sigmoidoscopy with flatus tube insertion Unstable - Urgent laparotomy
139
Palpable fullness in the gallbladder with painless jaundice?
Think pancreatic cancer
140
Fever, abdo pain, cirrhosis and portal HTN?
Think SBP
141
Hypertrophic pulmonary osteoarthropathy is associated with what?
Squamous cell carcinoma of lung
142
Achalasia increases the risk of what?
Squamous cell carcinoma of the oesophagus
143
What is the best way to assess someone response to Hep C treatment?
Viral load
144
Ongoing jaundice + pain post cholecystectomy?
Gallstone in common bile duct
145
Management of malignant distal obstructive jaundice due to unresectable pancreatic carcinoma
Biliary stenting
146
Flu like illness with RUQ pain, tender hepatomegaly and deranged LFTs?
Think Hep A
147
What would biliary colic blood show?
Everything normal
148
What should you not do in someone with suspected pancreatitis?
Make them nil by mouth - enteral feeding should be offered
149
What is the treatment for symptomatic perinala fistulae in Crohn's?
Oral metronidazole
150
History of vascular disease and lactic acidosis
Think mesenteric ischaemia
151
What is the most sensitive/specific test for pancreatitis?
Lipase
152
What is the marker of choice to assess liver synthetic function?
INR (prothrombin time)
153
What are some components of Child-Pugh score?
- Bilirubin - Albumin - PT - Encephalopathy - Ascites
154
What should be the first investigation in A+E if someone comes in with pain/vomiting?
Erect CXR to look for pneumoperitoneum suggestive of perforation
155
What are the components of Glasgow score for pancreatitis?
Pa02 Age > 55 Neutrophils Calcium < 2 Renal function Enzymes Albumin Sugar
156
Why is US scan helpful in pancreatitis?
Assess for presence of gallstones
157
What are the 2 signs of pancreatitis?
Grey Turners - Bruising along flanks suggestive of haemorrhagic pancreatitis (sign of retroperitoneal bleeding) Cullen - Bruising around umbilicus
158
Pigmented gallstones are associated with what?
Sickle cell anaemia
159
pseudomembranous colitis is what?
C diff colitis
160
What is the treatment for cholecystitis?
IV Abx with laparoscopic cholecystectomy within 1 week of diagnosis
161
What can be used to manage complex anal fistulae?
Draining seton
162
What is the most common disease pattern in UC and Crohns?
UC - Proctitis Crohns - Ileitis
163
What drugs should be stopped in C diff infection?
Opioids
164
anorectal pain and a tender lump on the anal margin
Thrombosed haemorrhoids
165
short incubation period and severe vomiting
Staph aureus gastroenteritis
166
Which Abx can be used for Campylobacter infection if severe/immunocompromised?
Clarithromycin
167
Charcot's triad plus hypotension and confusion
Reynolds pentad
168
What is necessary before a diagnosis of PBC?
Imaging to exclude a extrahepatic biliary obstruction
169
Management of acute anal fissues?
Bulk forming laxatives
170
What is Troisier's sign?
Enlarged hard left supraclavicular lymph node which indicates metastatic abdo malignancy
171
What are risk factors for gastric cancer?
- H pylori - Gastric polyps - Pernicious anaemia - Gastric ulceration
172
What does TNM staging assess?
Size of tumour Presence of lymph nodes Evidence of metastases
173
What is the marker for HCC?
AFP
174
Surgical procedures for pancreatic cancer?
- Pancreaticoduodenectomy - Whipples
175
flu-like symptoms, RUQ pain, tender hepatomegaly and deranged LFTs
Hepatitis A
176
Hepatitis serology
IgM - acute infection IgG - chronic infection
177
Severe hepatitis in a pregnant woman
Hep E
178
Man returns from trip abroad with maculopapular rash and flu-like illness
Think HIV seroconversion
179
Undercooked pork?
Hepatitis E
180
Right-sided tenderness on PR exam
Acute appendicitis
181
What is the surgery for bilateral/recurrent inguinal hernias?
Laparoscopic repair with mesh
182
Mesalazine can cause what?
Drug induced pancreatitis
183
lemon tinge to the skin
Pernicious anaemia
184
pH < 7.3 at 24 hours post paracetamol overdose?
Liver transplant consideration
185
periodic acid-Schiff- (PAS-) positive macrophages
Whipples disease
186
dysphagia, iron deficiency anaemia and glossitis
Plummer Vinson syndrome
187
What is a TIPS procedure?
Artifical channel within the liver used for variceal bleeding refractory ascites Major complication is hepatic encephalopathy
188
severe abdominal pain, ascites and tender hepatomegaly
Budd-Chiari syndrome
189
Which laxative to prescribe when starting patients on opiates?
Senna
190
Management of diverticulitis flare?
Oral Abx with admission to hospital if symptoms do not improve within 72 hours
191
Why give albumin for large volume ascites?
reduce paracentesis-induced circulatory dysfunction and mortality
192
What is usually normal with acute cholecystitis?
LFT tests
193
classic epigastric pain which is relieved on sitting forwards
Think chronic pancreatitis
194
What will AST:ALT ratio be in alcoholic hepatitis?
2:1
195
caput medusae and splenomegaly in a known alcoholic suggest what?
Portal HTN
196
Antibodies for PBC
Anti-mitochondrial - most common Anti-smooth muscle
197
What does a score of 3 or more on Glasgow criteria suggest for pancreatitis?
May need ITU input
198
slate-grey skin pigmentation
Haemochromatosis
199
Diarrhoea after rice?
Bacillus cereus
200
What are the anti emetics of choice in gastroparesis?
- Metoclopramide - Domperidone
201
fever, malaise, abdo pain and rose spots on trunk?
Typhoid fever -> treat with fluids and Ciprofloxacin
202
Raised ALP and bilirubin suggests what?
Cholestatic picture
203
What marker is raised in cholangiocarcinoma?
CA19-9
204
MSH2/MLH1 mutation?
HNPCC
205
What is the AST:ALT ratio in alcoholic liver disease?
2:1 - AST 2 times higher than ALT
206
Gastroenteritis incubation periods?
1-6 hours: Staph aureus 12-48 hours: Salmonella, E coli 48-72 hours: Shigella, Campylobacter >7 days: Giardiasis, Amoebiasis
207
mural thickening of the colon and the presence of pericolic fat stranding in the sigmoid colon
Diverticular disease
208
What is the weight loss definition for malnutrition?
Loss of >10% in the last 3-6 months
209
What should the prothrombin time be in order to qualify for liver transplant?
>100seconds
210
First line test for coeliac in GP?
Total IgA and IgA tissue transglutaminase
211
When should a repeat endoscopy be done after the start of PPI therapy for ulcer?
6-8 weeks
212
Autoimmune hepatitis antibodies?
Type 1 - ANA, anti-smooth muscle Type 2 - Anti-LKM-1
213
What can help to confirm SBP from Ascitic fluid?
Raised neutrophils
214
triad of vomiting, pain and failed attempts to pass an NG tube
Gastric volvulus
215
Post prandial vomiting and abdo pain in someone with chronic pancreatitis?
Pancreatic pseudocyst
216
Blockage where does not cause jaundice?
Cystic duct or gallbladder
217
ALT/AST in the 10,000s?
Think paracetamol overdose
218
AST vs ALT
AST - alcohol overdose ALT - drug overdose/viral hepatitis
219
Suspected cholecystitis in GP?
Refer to hospital for urgent admission
220
spiral or comma-shaped gram negative
Campylobacter
221
Ischaemia to the lower GI tract can result mainly into what 3 conditions?
1) acute mesenteric ischaemia 2) chronic mesenteric ischaemia 3) ischaemic colitis
222
Mesenteric ischaemia vs ischaemic colitis?
Mesenteric: small bowel (typically), due to embolism, sudden onset, severe symptoms, urgent surgery, high mortality. Ischaemic colitis: large bowel, multifactorial, transient, less severe symptoms, blood diarrhoea, 'thumbprinting', conservative Mx Both: ischaemia to lower GI tract, abdo pain
223
Predisposing factors to bowel ischaemia?
age, AF, smoking, HTN, DM, cocaine, other causes of emboli eg. endocarditis, malignancy
224
What is sometimes seen in young pts following cocaine use?
ischaemic colitis
225
Typical common features of bowel ischaemia?
abdo pain, rectal bleeding, diarrhoea, fever, elevated WBC associated with lactic acidosis
226
What do blood for bowel ischaemia show?
Elevated WBC associated with lactic acidosis
227
Ix for bowel ischaemia?
CT
228
Boerhaaves syndrome?
spontaneous rupture of oesophagus that occurs as a result of repeated episodes of vomiting; rupture usually left side and distal
229
CP of Boerhaaves syndrome (spontaneous rupture of oesophagus)?
sudden onset severe chest pain that may complicate (lead to or be accompanied by) severe vomiting severe sepsis secondary to mediastinitis
230
Diagnosis of Boerhaaves syndrome (spontaneous rupture of oesophagus)?
CT contrast swallow
231
Mx of Boerhaaves syndrome (spontaneous rupture of oesophagus)?
thoracotomay and lavage is <12hrs onset; >12hrs then insertion of T tube to create a controlled fistula between oesophagus and skin delays >24hrs associated with high mortality
232
Appendicitis?
Acute inflam of appendix (small narrow tube connected to the caecum)
233
Causes of appendicitis?
- luminal obstruction (50%) - unknown
234
Causes of luminal obstruction that may cause appendicitis?
- faceolith (hard mass of faecal matter) - lymphoid hyperplasia during infection - impacted stool - foreign body - appendiceal/caecal tumour
235
Appendicitis: luminal obstruction leads to...
distension of appendix due to increased mucus production, bacterial overgrowth and suppurative inflam -> impaired lymphatic and venous drainage from appendix -> eventual ischaemia and necrosis, and potential perforation
236
Peak incidence of appendicitis?
2nd and 3rd decade of life
237
Appendicitis can be characterised as what?
Uncomplicated (non-perforating) or complicated (perforating)
238
Cx resulting from delay or misdiagnosis of appendicitis?
perforation: abscess formation, peritonitis, sepsis, intra-abdo adhesions, bowel obstruction
239
Do all cases of appendicits result in perforation?
natural progression of acute appendicits results in perforation but some may not follow this course and will resolve spontaneously
240
CP of appendicitis?
- periumbilical or epigastric pain that worsens and migrates to lower quadrant (McBurneys) over 24-48hrs - pain aggrevated by movement - low-grade fever (<38), malaise, anorexia (loss of appetite) - N&V, constipation or diarrhoea - may present atypically in very young, elderly or pregancy and anatomical position of appendix may vary CPs
241
Signs on examination for appendicitis?
- tenderness in right lower quadrant, may be worse on coughing or hopping in children - abdo distension, guarding, rebound tenderness or percussion tenderness, or absent bowel signs (all may suggest peritonitis eg. if perforation has occured) - palpable abdo mass (appendix mass or abscess) - Rovsing's sign
242
Mx for suspected appendicits?
- emergency admission: specialist assessment - Imaging: if uncertain but delays surgery; USS (preg, child, breastfeeding), CT or MRI (if USS non-diagnostic) - Negative imaging= non-operative Mx if uncomplicated: IV fluids and Abx - GOLD= laparoscopic appendicectomy; can do explorative laparoscopy if progressive/persistent pain to establish/exclude diagnosis - or may do percutaneous drainage of appendix abscess
243
Possible post-op Cx from appendicectomy?
small bowel obstruction, superficial wound infection, intra-abdo abscess, stump leakage, stump appendicitis
244
What is the site of maximal tenderness in appendicitis called?
McBurney's point= 2/3rds of way along line drawn from umbilicus to anterior superior iliac spine
245
3 specific signs for acute appendicitis?
- Rovsing's sign - Psoas sign - Obturator sign
246
Appendicitis: Rovsing's sign?
palpation of left lower quadrant increased pain felt in right lower quadrant
247
Appendicitis: Psoas sign?
passive extension of right thigh with pt in left lateral position elicits pain in right lower quadrant
248
Appendicitis: Obturator sign?
passive internal rotation of flexed right thigh elicits pain in RLQ
249
How may appendicitis present in infants and young children?
non-specific abdo pain and anorexia, may appear withdrawn
250
How may elderly pts present with appendicitis?
minimal pain or fever, may present with acute confusion or shock
251
How may appendicitis present in pregnancy?
Right upper quadrant pain in later stages of pregnancy (appendix displaced by gravid uterus), N&V may be mistaken for pregnancy symptoms
252
If anatomical position of appendix is different in non-pregnant pt, where may it lie if they present with: right loin pain and tenderness, positive psoas test; muscular rigidity and tenderness to deep palpation absent (due to protection of overlying caecum)?
Retrocaecal/retrocolic appendix
253
If anatomical position of appendix is different in non-pregnant pt, where may it lie if they present with: vomiting and diarrhoea (due to irritation of distal ileum)?
pre-ileal and post-ileal appendix
254
If anatomical position of appendix is different in non-pregnant pt, where may it lie if they present with: suprapubic pain and urinary frequency, diarrhoea and tenesmus may be present due to rectal irritation, adbo tenderness lacking, rectal or vaginal tenderness present on right side; microscopic haematuria and lecuocytes +ve on urine dip?
Subcaecal and pelvic appendix
255
If anatomical position of appendix is different in non-pregnant pt, where may it lie if they present with: pain in left lower quadrant?
Long appendix with tip inflammation
256
Ix to exclude alternative cause in suspected appendicitis?
- FBC: neutrophil predominant and leucocytosis - CRP: raised or normal - Urine dip: exclude UTI - Pregnancy test
257
What pts are most likely to be diagnosed with appendicitis clinically?
thin male
258
Acute cholecystitis?
Inflamm of gallbladder, usually when gallstone completely obstructs gallbladder neck or cystic duct
259
Acalculous cholecystitis?
gallbladder inflam without gallstones; 5-14%. Typically in critically ill people due to combination of RFs resulting in bile stasis (due to gallbladder hypo/dysmotility) or bile thickening (dehydration)
260
Cause of acalculous cholesystitis?
- unknown, but ?functional cystic duct obstruction often present and associated with bile stasis or thickening - critically ill pts - or predisposition to bacterial colonisation of static gallbladder bile.
261
Without treatment, what happens to pt with acute cholecystitis?
May resolve spontaneously within 1-7days; 25-30% will need surgery
262
Cx of acute cholecystitis?
- gangrenous cholecystitis (necrosis of gallbladder wall) - perforation of gallbladder - biliary peritonitis - pericholecystic abscess - fistula (between GB and duodenum) - Jaundice - Sepsis
263
Why may pt with acute cholecystitis develop jaundice?
Due to inflam of adjoining biliary ducts- Mirizzi's syndrome
264
CP of acute cholecystitis?
- sudden-onset, constant, severe pain in upper right quadrant, lasting several hrs - tenderness, with or without guarding, in RUQ - fever, anorexia, N&V, back or shoulder pain, RUQ mass, +ve murphy's sign
265
Mx for all pts with suspected acute cholecystitis?
- admit - Confirm diagnosis= abdo USS and bloods (WCC, CRP, serum amylase) - Monitoring (BP, pulse, urine ouput) - Treatment (IV fluids, Abx, analgesia) - Surgical assessment= cholecystectomy
266
Type of pain in acute cholecystitis?
- constant, several hrs; can be shorter if gallstone returns to gallbladder lumen or passes into duodenum - severe, steady - may radiate to the back - referred pain from gallbladder felt in right shoulder or interscapular region
267
When can pt get referred pain in acute cholecystitis?
Right shoulder or interscapular region
268
What to ask pt with suspected acute cholecystitis?
previous episodes of gallstones or biliary colic (90% have gallstones); (50% who have had one episode of biliary pain will have another within 12m)
269
RFs for acute cholecystitis?
- recent illness - trauma - female - age - obesity - lower fibre diet
270
Signs of sepsis?
- acute deterioration in pt with strong suspicion of infection - extreme pain, mottled skin, fever or reduced core temp, rigors or chills and/or SOB - non-specific= acutely inwell with normal temp - severe= evidence of multi-organ dysfunction and shock
271
Murphy's sign in acute cholecystitis?
inspiration is inhibited by pain on palpation when hand is positioned along costal margin; unreliable in older pts
272
Mirizzi's syndrome? (acute cholecystitis)
Gallstone becomes lodged in neck of gallbladder or cystic duct; leads to compression of common hepatic duct causing bile obstruction -> can lead to jaundice.
273
Differential diagnosis for acute cholecystitis?
- acute cholangitis - ACS - acute pancreatitis - appendicitis - GI cancer - GORD - hepatitis - peptic ulcer - right lower lobe pneumonia - symptomatic gallstones
274
LFTs in acute cholecystitis?
typically normal; if deranged may indicate Mirizzi syndrome
275
Ix for acute cholecystitis?
USS first line
276
Treatment for acute cholecystitis?
IV Abx + early laparoscopic cholecystectomy within 1w of diagnosis
277
Conditions associated with biliary stasis or thickening?
sepsis, extensive trauma, burns, major surgery, prolonged fasting
278
Differential diagnosis for appendicitis?
GI: - gastroenteritis - intestinal obstruction - incarerated inguinal hernia - intussusception - malrotation of midgut - Meckel diverticulum - Biliary colic and acute cholecystitis - perforated peptic ulcer - diverticulitis - pancreatitis - IBD, IBS, constipation Urological: - right ureteric colic - right pyleonephritis - UTI - urinary retention - testicular torsion Gynae: - ectopic - ruptured ovarian cyst/torsion - Mittelschmerz - PID - Endometriosis, adenomyosis - fibroids Other: - penumonia - lumbar discitis - non specific abdo pain - mesenteric adenitis - abdo wall abscess/haematoma - DKA - shingles
279
Acute pancreatitis?
Acute inflam process of pancreas with varying involvement of local tissues or more remote organ systems; may not be possible to identify severity based on CP
280
Classification of severity of acute pancreatitis?
Mild, moderatley severe, severe, recurrent
281
Mild acute pancreatitis?
absence of local or systemic Cx or organ failure; uneventful recovery and resolves in first week. MOST COMMON
282
Moderately severe acute pancreatitis?
local Cx and/or transient organ failure that resolves within 48hrs
283
Severe acute pancreatitis?
persistent single or multiorgan failure for >48hrs
284
Recurrent acute pancreatitis?
occurs on more than once occasion with full recovery between episodes
285
Causes/RFs of acute pancreatitis?
- gallstones or alcohol misuse (75%) - post-endoscopic procedures - trauma - surgery - hyperglyceridaemia - hypercalcaemia - drugs - chronic pancreatitis - anatomical disorders - autoimmune conditions - pancreatic malignancy - previous episodes - FHx
286
Local Cx of acute pancreatitis?
pancreatic necrosis, pseudocyst, abscess, fistulae, thrombosis, haemorrhage
287
Systemic Cx of acute pancreatitis?
multiorgan failure and sepsis, AKI, acute resp distress syndrome
288
CP of acute pancreatitis?
- acute sudden onset upper or generalised abdo pain, may be associated with N&/or V, RFs - signs of shock, fever, sepsis, abdo tenderness and distension
289
Mx for suspected acute pancreatitis?
- emergency hospital admission for specialist assessment and Mx
290
Type of pain in acute pancreatitis?
- severe sudden which becomes constant - localised to epigastric region, right and/or left UQ - may radiate to BACK or flanks - generalised with peritonism if peritonitis present - may be sudden and sharp if caused by gallstones - if alcohol related= less abrupt onset and poorly localised degree of pain does not reflect severity
291
Signs of shock? eg. in acute pancreatitis
tachycardia, tachypnoea and hypotension
292
What signs are sometimes associated with complicated haemorrhagic pancreatitis (rare)?
- Cullen's sign - Grey-Turners sign - Fox's sign
293
Cullen's, Grey-Turner's and Fox's sign (in acute complicated haemorrhagic pancreatitis)?
Ecchymoses (buish discolouration) around umbilicus (CULLEN'S), the flanks (GREY-TURNER'S) or over inguinal ligament (FOX'S)
294
Differential diagnosis for acute pancreatitis?
- perforated peptic ulcer - bowel obstruction - ischaemic bowel - ruptured AAA - ruptured ectopic - MI - biliary colic, acute cholecystitis, cholangitis - gastroenteritis - viral hepatitis - appendicitis
295
Specialist assessment and Mx of acute pancreatitis?
Initial: - resus with IV fluids (crystalloid, aim for urine output >0.5ml/kg/hr - sup O2 - IV analgesia - IV Abx if infected pancreatic necrosis - early nutritional support: enteral nutrition (parenteral feeding if unable to tolerate oral intake) Surgical: - endoscopic retrograde cholangiopancreatography (ERCP) to relieve obstruction within 72hrs onset of symptoms= gallstones & cholangitis, jaundice or common bile duct obstruction - Cholesystectomy= mild acute gallstone pancreatitis arranged during same addmission or deferred until after resolution of severe AP - Purcutaneous or endoscopic drainage of pancreatic collections and potential Mx of other Cx eg. debridement of necrotic tissue
296
Initial specialist Ix for acute pancreatitis?
- Bloods= lipase, amylase, liver and renal function, CRP & ESR - USS (limited but may detect gallstone); CT or/and MRI - if not improving or underlying cause known= magnetic resonance cholangiopancreatography (MRCP) and/or endoscopic ultrasonography (EUS)
297
Should you follow up pt with acute pancreatitis?
If have confirmed diagnosis and been discharged from hospital - advice and support - Mx RFs
298
Pathophysiology of pancreatits?
autodigestion of pancreatic tissue by prematurely activated pancreatic enzymes leading to necrosis
299
What condition may show Cullen's sign (periumbilical discolouration) and Grey-Turner's sign (flank discolouration) but is rare?
Acute pancreatitis
300
Rare features associated with pancreatitis?
ischaemic (Purtscher) retinopathy: may cause temp or permanent blindness
301
In acute pancreatitis, 75% of pts have raised amylase (>3times upper limit of normal); this does not colerate with disease severity; but what are other causes of raised amylase?
pancreatic pseudocyst, mesenteric infarct, perforated viscus, acute cholecystitis, DKA
302
Is serum lipase useful in acute pancreatitis?
more sensitive and specific than amylase, has long half-life so useful for late presentations >24hrs
303
When can diagnosis be made for acute pancreatitis?
1) without imaging if characteristic pain + amylase/lipase >3 times normal level BUT early USS imaging important to assess aetiology (eg. gallstones/biliary obstruction) or contrast-CT
304
Specific scoring systems for acute pancreatitis?
Glasgow score; Ranson score and APACHE II
305
Common factors that may indicate severe pancreatitis?
- >55yrs - hypocalcaemia - hyperglycaemia - hypoxia - neutrophilia - elevated LDH and AST
306
Causes of acute pancreatitis (using mnemonic)?
GET SMASHED G.allstones E.thanol T.rauma S.teroids M.umps (& coxsackie B) A.utoimmune eg. polyarteritis nodosa, SLE S.corpion venom H.ypertrigluceridaemia, hypercalcaemia, hypothermia E.RCP D.rugs
307
Drugs that may cause acute pancreatitis?
azathioprine, mesalazine, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valporate
308
Acute pancreatitis local Cx: peripancreatic fluid collections?
25% Located in or near pancreas and lack a wall of granulation or fibrous tissue May resolve or develop into pseudocysts or abcessess Most resolve so avoid apiration and drainage and may cause infection
309
Acute pancreatitis local Cx: psudeocysts?
Result from collection of peripancreatic fluid. Walled by fibrous or granulation tissue and occurs 4w+ after. Retrogastric. 75% have persistent mild elevation of amylase Ix= CT, ERCP and MRI or endoscopic USS Symptomatic- observe for 12w as 50% resolve Mx= endoscopic or surgical cystogastrostomy or aspiration
310
Acute pancreatitis local Cx: pancreatic necrosis?
May invl pancreatic parenchyma and surrounding fat. Cx linked to extent of necrosis. Early necrosectomy associated with high mortality rate (so avoid unless really indicated). Sterile necrosis= Mx conservatively
311
Acute pancreatitis local Cx: pancreatic abscess?
Intraabdo collection of pus associated with pancreas but absent of necrosis. As result of infected psudeocyst. Mx: transgastric drainage or endoscopic drainage
312
Acute pancreatitis local Cx: haemorrhage?
Infected necrosis may involve vascular structures with resultant haemorrhage that may occur de novo or as result of surgical necrosectomy. Grey-Turner's sign.
313
Alcoholic liver disease covers a spectrum of what conditions?
- alcoholic fatty liver disease - alcoholic hepatitis - cirrhosis
314
Ix for alcoholic liver disease?
- gamma-GT elevated - AST:ALT is normally >2, a ratio of >3 is suggestive of acute alcoholic hepatitis
315
Mx for alcoholic hepatitis (alcohol liver disease)?
- Glucocorticoids eg. pred used during acute episodes (determined using Maddrey's discriminant function-DF calculated using prothrombin time and bilrubin conc)
316
Cirrhosis?
Progressive liver disease due to chronic inflam of liver, usually over 1-20yrs
317
What happens in liver cirrhosis?
normal liver structure becomes distorted with regenerative nodules surrounded by diffuse fibrosis, affecting synthetic, metabolic and excretory actions
318
Types of cirrhosis?
Compensated cirrhosis and decompensated cirrhosis
319
When does a transition from compensated to decompensated cirrhosis occur in some people?
Due to the development of portal HTN and/or hepatocellular dysfunction
320
Compensated cirrhosis?
inital largely asymptomatic phase when liver still functions effectively
321
Decompensated cirrhosis?
symptomatic phase with potentially life-threatening Cx eg. jaundice, ascites, hepatic encephalopathy and/or variceal bleeding
322
RFs for cirrhosis?
- increased alcohol intake - hep A & C - autoimmune liver disease - hameochromatosis or Wilson's - Drug-induced liver injruy - obsesity and/or DMT2 if also NAFLD and increased risk of advanced liver fibrosis
323
Cx of cirrhosis?
- malnutrition and frailty - osteoporosis - infection & sepsis incl. spontaneous bacterial peritonitis - jaundice - ascites - hepatic encephalopathy - variceal bleeding - AKI - hepatorenal syndrome - heptatocellular carcinoma
324
CP of cirrhosis?
- pt has RFs - non-sepcific= malaise, fatigue, anorexia, weight loss, muscle wasting - Symptoms of chronic liver disease - Signs of chronic liver disease - Abnorm LFTs but may be normal
325
Symptoms of chronic liver disease eg. in cirrhosis?
abnom bruising, bleeding or itch
326
Signs of chronic liver disease eg. in cirrhosis?
hepatosplenomegaly, spider naevi, clubbing, palmar erythema, proximal nail bed pallor signs of decompensation eg. jaundice peripheral oedema, ascites or hepatic encephalopathy
327
Signs of decompensation in cirrhosis?
jaundice, peripheral oedema, ascites, hepatic encephalopathy
328
Ix for cirrhosis?
- LFTs - FBC - albumin - clotting screen and INR - Hep B and C serology - autoantibodies and serum Ig - Fibrosis-4 (FIB-4) score - Transient elastography to confirm
329
What may bloods for liver disease/cirrhosis show?
- LFTs and bloods: low platelet, raised AST:ALT, high bilirubin, low albumin or increased prothrombin time or INR
330
When to refer pt with ?cirrhosis?
- decompensated liver disease= hospital admi or immediate referral to hepatologist or gastroenterologist - newly diagnosed following imaging= refer hepato or gastro - alcohol-related liver disease= specialist alcohol services - end-stage liver disease= palliative MDT if eg. ongoing alcohol use, irrevsersible disease unsuitable for transplant; 2 unplanned liver admissions in last 6m or heaptocellular ca best appropritate for supportive care
331
Primary care Mx for cirrhosis?
- info - ensure under specialist follow up for Mx of underlying cause and monitoring for Cx - lifestyle advice - assess malnutrition risk, ?dietician - osteoporosis risk - vaccines up to date - review meds in relation to liver function - Cx
332
Are liver blood tests for cirrhosis accurate?
Can be normal. Can be abnormal due to other conditions eg. acute intercurrent illness, bone marrow disease, haemolysis
333
When to offer referral for transient elastography (or hepato/gastro if not available) if pt is at risk of cirrhosis?
at risk + - hep C infection - increased alcohol intake - or known-related liver disease
334
?cirrhosis and known hep B infection?
refer gastro
335
?cirrhosis and known NAFLD and advanced liver fibrosis (based on elevated non-invasive advanced liver fibrosis risk score)?
Referral for transient elastography or acoustic radiation force impulse elastography to diagnose cirrhosis
336
?cirrhosis and pt obese and/or DMT2?
do not offer tests to diagnose cirrhosis unless they have NAFLD and advanced liver fibrosis
337
?cirrhosis in pt with additional liver (eg. PBC, PSC, haemochromatosis, Wilson's)?
liase with pt's specialist or refer to heapto/gastro
338
What if ?cirrhosis but cirrhosis is not diagnosed on initial testing?
ensure retesting for cirrhosis every 2yrs for: - pt with alcohol-related liver disease - hep C and not shown response to antivirals - NAFLD and advanced liver fibrosis
339
Anal fissure?
tear or ulcer in squamous lining of distal anal canal which causes pain on defecation
340
How are anal fissures classifed?
- acute= <6w - chronic= 6w+ - primary= no clear underlying cause - secondary= clear underlying cause
341
Underlying causes of anal fissure?
- unknown - constipation, IBD, STI, colorectal ca
342
Peak incidence of anal fissure?
15-40yrs; primary uncommon in elderly so warrant further Ix
343
CP of anal fissure?
- anal pain with defacation, - with or without bright red rectal bleeding - tearing sensation on passing stool - anal spasm
344
External examination of the anus may reveal what if a pt has anal fissure?
linear split in anal mucosa
345
Examination findings of acute anal fissure?
superficial with well-demarcated edges
346
Exam finding of chronic anal fissure?
wider and deeper with muscle fibres visible in the base; edges often swollen and a skin tag may be visible at the end of the fissure
347
Exam findings of primary anal fissure?
posterior midline, but 10% occur anteriorly (esp women)
348
Exam findings of secondary anal fissure?
irregular outline, multiple or occur laterally
349
What may be needed if it is difficult to examine for anal fissure eg. if pain or anal spasm; or if diagnosis unclear?
Referral for exam under anaesthesia
350
Mx of anal fissure?
- refer if serious underlying cause suspected - dietary and lifestyle advice - simple analgesia and measures to reduce pain: petroleum jelly lubricatn before defecation - short course topical anaesthetic if extreme pain on defecation - persisted 1w+ without improvement= rectal GTN ointment 6-8w - no improvement after topical GTN= botulinum toxin pr ?surgery (sphincterotomy) - secondary fissure: refer if serious or TUC
351
Lifestyle advice for pt with anal fissure?
ensure stools soft and easy to pass (high fibre intake, increased fluid intake); good anal hygiene to aid healing; soak in warm shallow bath
352
When should adults with primary anal fissure be reviewed?
6-8w advice to reduce risk of recurrence refer to general or colorectal surgeon if unhealed
353
When should specialist advice be sought in children with anal fissure?
if not healed after 2w or sooner if signif pain
354
Differential diagnosis for anal pain with or without bleeding?
- haemorrhoids - IBD - sarcoidosis - infection eg. TB, HIV, syphilis - maligancy eg. anal carcinoma or lymphoma - peri-anal abscess
355
Ascending cholangitis?
Bacterial infection (typically E.coli) of biliary tree
356
Most common predisposing factor for ascending cholangitis?
gallstones
357
Charcot's triad occurs in 20-50% pts with what?
ascending cholangitis
358
Ascending cholangitis: Charcot's triad?
RUQ pain Fever Jaundice
359
Ascending cholangitis: Reyonold's pentad?
RUQ pain Fever Jaundice + hypotension and confusion
360
Feature of ascending cholangitis?
- fever, RUQ pain, jaundice, hypotension, confusion - raised inflam markers
361
Ix for ascending cholangitis?
USS first like= bile duct dilation and bile duct stones
362
Mx for ascending cholangitis?
IV Abx + Endoscopic retrograde cholangiopancreatography (ERCP) after 24-48hrs to relieve any obstruction
363
Ascites?
Abnormal accumulation of fluid in abdomen
364
Causes of ascites can be grouped into what?
a gradient of <11g/L or a gradient >11g/L
365
What does SAAG mean?
Serum-Ascites Albumin Gradient= calculation to determine cause of ascites. SAAG= Serum Albumin - Ascitic Fluid Albumin
366
SAAG ≥ 11 g/L meaning in ascites?
ascites is due to portal hypertension
367
SAAG <11g/L meaning in ascites?
ascites due to causes other than portal hypertension
368
Causes of ascites with SAAG ≥ 11 g/L (indicates portal hypertension)?
- LIVER DISORDERS (most common)= cirrhosis/alcoholic liver disease; acute liver failure; liver mets - Cardiac= RHF, constrictive pericarditis - Other= Budd-Chiari syndrome; portal vein thrombosis; veno-occlusive disease; myoxedema
369
Causes of ascites with SAAG <11g/L?
- Hypoalbuminaiea= nephrotic S; severe malnutrition eg. Kwashiorkor - Malignancy= peritoneal carinomatosis - Infections= TB peritonitis - Other= pancreatitis; bowel obstruction; biliary ascites; post op lymphatic leak; serositis in connective tissue diseases
370
Mx for ascites?
- reduce dietary sodium and fluid restriction if sodium <125mmol/L - aldosterone antagonists eg. spironolactone (and often + loop diuretics) - drainage if tense ascites (therapeutic abdo paracentesis) - prophylactic oral ciprofloxacin to reduce risk of spontaneous bacterial peritonitis if cirrhosis + ascites with ascitic protein of 15g/L or less, until ascites has resolved - transjugular intrahepatic portosystemic shunt (TIPS) may be considered in some pts
371
Large volume paracentesis for the treatment of ascites requires what?
Albumin 'cover'; this reduces paracentesis induced circulatory dysfunction and mortality
372
Paracentesis induced circulatory dysfunction eg. in ascites?
can occur due to large vol paracentesis (>5 litres); associated with high rate of ascited recurrence, hepatorenal syndrome, dilutional hyponatraemia and high mortality
373
Biliary colic?
Colicky RUQ abdo pain caused by gallstones passing through the biliary tree
374
RFs for biliary colic and gallstone related disease?
Fat Female Fertile (pregnancy) Forty DM, crohns, rapid weight loss (eg. weight reduction surgery), drugs
375
Why is obesity a RF for biliary colic?
enhanced cholesterol synthesis and secretion
376
Why is female a RF for biliary colic?
oestrogen increases activity of HMG-CoA reductase so gallstones 2-3x more common in women
377
What drugs are RFs for biliary colic?
fibrates, COCP
378
Pathophysiology of biliary colic?
occur due to increased cholesterol, decreased bile salts and biliary stasis. pain occurs due to gallbladder contracting against stone lodged in cystic duct
379
CP of biliary colic?
- colicky (intermittent, crampy) RUQ pain - worse postpradnially (after eating, espec fatty foods) - pain may radiate to right shoulder/interscapular region - N&V - NO FEVER and LFTS/INFLAM markers NORMAL: in contrast to other gallstone related conditions
380
Where may biliary colic pain radiate?
R shoulder and interscapular region
381
Ix for biliary colic (gallstone disease)?
abdo USS and LFTs if not detected on USS but high suspecion then MRCP or endoscopic USS (EUS)
382
Mx for biliary colic (gallstone disease)?
referral for elective laparoscopic cholescystectomy
383
Why may some pts with gallstones experience ongoing jaundice and pain after cholecystectomy?
gallstones may be in the common bile duct (choledocholithiasis)
384
Cx of gallstones?
- biliary colic - acute cholecystitis (common) - ascending cholangitis - acute pancreatitis - gallstone ileus - gallbladder ca
385
Choledocholithiasis?
Gallstone in common bile duct
386
Cholelithiasis?
Gallstones
387
What is a gallstone (cholelithiasis)?
solid deposit that forms within gallbladder
388
Gallstone disease?
general term that describes presence of 1+ stones in gallbladder or other parts of the biliary tree, and the symptoms and Cx they may cause
389
When do gallstones occur?
when there is a problem relating to the chemical composition of bile; can result in precipitation of 1 or more of the constituents
390
Cholesterol gallstone formation is a result of what 3 defects?
cholesterol supersaturation, accelerated cholesterol crystal nucleation and impaired gallbladder motility
391
What type of diet is associated with gallstones?
high in triglycerides and refined carbs and low in fibre
392
What medication is associated with gallstones?
somatostatin analogues, glucagon-like peptide-1 analogues and ceftriaxone
393
Is treatment needed for pts with asymptomatic gallstones found in normal gallbladder and with a normal biliary tree?
No
394
When should referral be made for bile duct clearance and laparoscopic cholecystectomy in pt with asymptomatic gallstones?
if gallstones found in the common bile duct
395
When should urgent referral be made for pt with known gallstones?
known gallstones + jaundice or if suspicion of biliary obstruction eg. signif abnormal LFTs
396
What to do after referring pt with ?gallstones whilst they are waiting for secondary care assessment for possible surgery?
Analgesia: severe pain= diclofenac or opioid IM mild to moderate intermittent pain= paracetamol or NSAIDs
397
Cholestasis?
blockage to flow of bile
398
Cholecystitis?
inflam of gallbladder
399
Cholangitis?
inflam of bile ducts
400
gallbladder empyema?
pus in gallbladder
401
cholecystectomy vs cholecystostomy?
cholecystectomy= surgical removal of gallbladder cholecystostomy= inserting drain into gallbladder
402
Most gallstones are made from what?
cholesterol
403
Liver and gallbladder anatomy?
right and left hepatic duct leave liver and join together to form common hepatic duct. cystic duct from gallbladder joins with common hepatic duct halfway along forming the common bile duct. pancreatic duct from pancreas joins with common hepatic duct further along when the common bile duct and pancreatic duct join they become the ampulla of Vater which opens into the duodenum. Sphincter of Oddi is a ring of muscle surrounding ampulla of Vater that controls the flow of bile and pancreatic secretions into the duodenum.
404
Where does bilirubin drain and what does raised bilirubin with pale stools and dark urine represent?
Drains from liver, through bile duct and into intestines/ Raised bilirubin (jaundice) with pale stools and dark urine represents obstruction to flow within the biliary system eg. by a gallstone in bile duct or external mass pressing on bile ducts (eg. cholangiocarcinoma or tumour of head of pancreas.
405
What is ALP and what does it mean if it is raised?
Alkaline phosphatase. Non-specific marker. Enzyme originating in liver, biliary system and bone. Abnormal results indicate liver or bone problems. Raised= pregnancy (produced by placenta); biliary obstruction; liver or bone malignancy; primary biliary cirrhosis; Paget's disease of bone.
406
What is ALT and AST?
Alanine aminotransferase and aspartate aminotransferase. Enzymes produced in the liver. Markers of hepatocellular injury (damage to liver cells).
407
ALT and AST slightly high, with a higher rise in ALP?
obstructive picture eg. gallstones
408
ALT and AST high compared with ALP?
hepatitic picture (hepatocellular injury)
409
MRCP (magnetic resonance cholangio-pancreatography)?
MRI scan that produces detailed image of biliary system; very sensitive and specific for biliary tree disease eg. malignancy and stones in bile duct. Eg. used if USS doesn't show stones in duct but there is bile duct dilation or raised bilirubin suggestive of obstruction
410
ERCP (endoscopic retrograde cholangio-pancreatography)?
insert endoscope down oesophagus, past stomach, to duodenum and opening of common bile duct (sphinter of Oddi) to access biliary system. Indication= clear stones in bule ducts
411
Coeliac disease?
chronic immune mediated systemic disorder in genetically predisposed people, triggered by exposure to dietary gluten.
412
What is gluten?
major complex protein component of wheat, barley and rye
413
Non-responsive coeliac disease?
persistent symptoms and enteropathy that do not respond after 6-12m on self-reported gluten-free diet
414
Refractory coeliac disease?
persistent or recurrent symptoms and villous atrophy on duodenal biopsy, despite strict adherence to gluten-free diet for at least 12m
415
Cx of undiagnosed, untreated or undertreated coeliac disease?
Reduced QOL; faltering growth in children; nutritonal def incl. anaemia; reduced BMD; hyposplenism; malignancy; refractory coeliac disease
416
What malignancy are pts with undiagnosed, untreated or undertreated coeliac diease at higher risk for?
Lymphoma and small bowel adenocarcinoma
417
Conditions associated with coeliac disease?
- DMT1 - autoimmune thyroid disease - autoimmune liver disease - selective IgA def - first degree relative affected
418
When to suspect coeliac disease?
persistent unexplained GI symptoms; IBS; faltering growth, short stature or delayed puberty in children; prolonged fatigue; persistent or recurrent mouth ulcers; unexplained iron, vit B12 or folate def; suspected dematitis herpetiformis; DMT1; selective IgA def
419
Consider coeliac disease in pt with what?
- unexplained dep or anxiety - osteromalacia, penia or porosis, or fragility fractures - unexplained peripheral nueropathy, ataxia; recurrent miscarriage or subfertility; persitently raised liver transaminases (mild elevation of ALT and AST) - dental enamel defects - hyposplenism or asplenia - Down's, Turner or William's syndrome
420
Ix for coeliac disease?
- height, weight, abdo exam and skin - Coeliac serology testing - Gastro referral for endoscopic intestinal biopsy (duodenal biopsy) if serology suggests possible diagnosis - If serology -ve but high clinical suspicion: consider referral
421
What should pt do before coeliac serology testing?
ensure eaten gluten-containing foods for min 6w before testing
422
Mx for coeliac disease?
- education and supporrt - long-term gluten free diet
423
What to assess for in pts with coeliac disease?
- persistent or recurrent symptoms despite adherence - growth and nutritional statis - osteoporosis risk and ?DEXA scan - nutrient def incl. annual blood monitoring - Cx or associated conditions - referral to dietitian to check dietary adherence and advise on deficiencies
424
When to refer pt with coeliac disease to appropriate specialist?
if non-responsive or refractory disease or serious Cx
425
What to give coeliac pts who have hyposplenism?
influenza, meningococcal and pneumococcal immunisation (P booster every 5yrs)
426
Signs and symptoms of coeliac disease are what?
non-specific and may present with intestinal and extra-intestinal manifestations or be asymptomatic.
427
CP of coeliac disease?
- Persistent unexplained GI symptoms eg. acid reflux, diarrhoea, steatorrhoea, weight loss, abdo pain, reduced appetite, bloating, constipation - Prolonged fatigue - Aphthous ulcers: persistent or recurrent - Suspected dermatitis herpetiformis
428
Dermatitis herpetiformis?
immune mediated cutaneous manifestation of coeliac disease. Symmetrical clusters of itchy blistering skin lesions followed by erosions, excoriations and hyperpigmentation; common on elbows, knees, shoulders, face, sacrum and buttocks.
429
2 possible extra-intestinal manifestations of coeliac disease?
Aphthous ulcers Dermatitis herpetiformis
430
Coeliac serology testing?
1st= total IgA and IgA tissue transglutaminase (tTGA) 2nd line if IgA tTGA unavailable or weakly +ve= anti-EMA antibodies (serum IgA endomysial antibody)
431
Equivocal coeliac serology result?
- adults= if IgA and tTGA equivocal do anti-EMA antibodies - children= refer to paeds gastro
432
Negative coeliac serology test result?
- IgA, tTGA or IgA EMA negative then check for IgA deficiency - if def present= will cause false-negative IgA - if IgA tTGA negative and IgA normal then truly negative and coeliac disease unlikely at present; doesn't rule out it developing in fututre - strongly suggested but negative= referral
433
Differential diagnosis for coeliac disease?
- infective gastroenteritis - non-coeliac gluten sensitivity - food allergy eg. wheat or cows milk - AIDS enteropathy - crohns - IBS - diverticular disease - malignancy - lactose intolerance - pancreatic exocrine insufficiency - peptic ulcer disease
434
Annual blood monitoring for coeliac disease (consider)?
- coeliac serology (adherence) - FBC & ferritin - TFTs - LFTs - calcium, vit D, vit B12 and folate
435
Gluten-free dietary advice?
avoid.. - foods based on wheat, barley and rye eg. cereals, bread, flour, pasta, cakes, biscuits, pasteries - foods that may contain it as fillers or flavouring eg. sausages, ready meals, soups, sauces - ?contaminated with gluten during packaging eg. oats, chips- that fried in same as battered fish - items that contain malt eg. beers - food labelled: gluten free, very low gluten or crossed grain symbol can be eaten - avoid risk of cross-contamination at home, travelling, eating out - alternative sources of starch eg. corn, rice, potatoes
436
In coeliac disease, repeated exposure to gluten causes what?
villous atrophy which causes malabsorption
437
Genetic association in coeliac disease?
HLA-DQ2 and DQ8
438
What does duodenal biopsy +ve for coeliac disease show?
- villous atrophy - crypt hyperplasia - increase in intraepithelial lymphocytes - lamina propria infiltration with lymphocytes
439
When do children normally present with coeliac disease?
before age of 3 eg. following introduction of cereals into diet. Failure to thrive, diarrhoea, abdo distension. Many cases not diagnosed till adulthood.
440
Does villous atrophy and immunology in coeliac disease reverse on a gluten free diet?
Yes
441
Diverticula?
sac-like protrusions of mucosa through muscular wall of colon
442
Diverticula occur where in around 80% of people >85yrs?
sigmoid colon
443
Diverticulum formation may be associated with what?
low-fibre diet
444
Majority of people with diverticula have symptoms where?
Left lower abdo. Minority eg. Asian may be sided sided.
445
Diverticulosis?
Condition where diverticula are present without symptoms.
446
What may diverticulosis present with?
Large, painless rectal bleed or found incidentally during Ix for other symptoms.
447
Diverticular disease?
Condition where diverticula cause symptoms eg. intermittent lower abdo pain, without inflammation and infection.
448
Diverticulitis?
Condition where diverticula become inflamed and infected.
449
Diverticulitis CP?
intermittent lower left quadrant abdo pain, fever, malaise, change in bowel habit and occasionally rectal bleeding
450
Uncomplicated diverticulitis?
Diverticular inflam that does not extend to the peritoneum
451
Complicated diverticulitis?
diverticulitis associated with Cx such as abscess, peritonitis, fistula, obstruction or perforation
452
Risk of diverticula increases with...
age rare <40yrs
453
Mx for confirmed diverticulosis?
- bulk forming laxatives if constipation - balanced high fibre diet - exercise, stop smoking
454
Mx for diverticular disease?
- urgent admission if signif rectal bleeding - avoid NSAIDs and opiods eg. codeine - advice on diet, lifestyle, fluid intake, stop smoking, exercise - bulk-forming laxatives, simple analgesia or antispasmodic eg. mebeverine - reassess if persistent or don't respons
455
Mx for acute diverticulitis and uncontrollable pain with any features of complicated acute diverticulitis?
Urgent hospital admission: IV Abx, fluid replacement and analgesia. Urgent surgery if don't improve or elective if recurrent.
456
Mx for uncomplicated diverticulitis?
- oral Abx if systemically unwell - systemically well= no Abx - analgesia - re-present if persist or worsen - referral to secondary care if symptoms persist or deteriorate - specialist referral to colorectal surgery if frequent or severe recurrent episodes of acute diverticulitis
457
When to suspect a Cx of diverticulitis?
uncontrolled abdo pain with... - abdo mass or peri-rectal fullness on PR (intra-abdo abscess) - abdo rigidity, guarding, rebound tenderness (perforation & perionitis) - altered mental state, raised resp rate, low SBP, tachy, low temp, no urine output or skin discolouration (sepsis) - faecaluria, pneumaturia, pyruia or passage of faseces through vagina (colovesical fistula) - colicky abdo pain, absolute contstipation, vomiting or abdo distension (intestinal obstruction)
458
Ix for diverticular disease?
- abdo exam; possible pelvic and digital rectal - referral for imaging or endoscopy to confirm if appropritate - Consider= FBC; faecal occult blood test; U&E; Kidney function; urinalysis; CRP
459
Example of an antispasmodic?
mebeverine
460
Oral Abx for acute uncomplicated diverticulitis if systemically unwell?
co-amoxiclav 500/125mg 3x daily for 5d or cefalexin 500mg twice daily for 5d
461
Surgical opitions for acute complicated diverticulitis who don't respond to medical Mx?
- percut drainage of large abscess - laparoscopic lavage - simple colostomy formation - sigmoid resection with colostomy (Hartmann's procedure) - Sigmoid resection with primary anastomosis with or without a diverting stoma
462
What is a diverticula and where is the usual sight? (histologically)
herniation of colonic mucosa through muscular wall of colon usual site is between taenia coli where vessels pierce the muscle to supply the mucosa; for this reason, the rectum (lack taenia) is often spared
463
Specialist Ix for diverticular disease?
- colonoscopy, CT cologram or barium enema= all can identify diverticular disease - Acutely unwell= plain abdo film and erect CXR to identify perforation; contrast CT abdo and pelvis= to identify acute inflam and presence of local Cx eg. abscess formation
464
Peptic ulcer disease includes what?
Gastric or duodenal ulcers
465
Peptic ulcer disease?
breach in the epithelium of gastric or duodenal mucosa, which is confirmed on endoscopy
466
Most common RFs for development of peptic ulcer disease?
Helicobacter pylori infection and NSAIDs/aspirin
467
Cx of peptic ulcer disease?
haemorrhage, perforation, gastric outlet obstruction
468
Ix of peptic ulcer disease?
- H.pylori test
469
Mx of peptic ulcer disease?
- lifestyle advice, review meds and assess for stress, anx & dep - H.pylori +ve= full dose PPI 2m + H.pylori eradication therapy - H.pylori -ve= full dose PPI 4-8w If proven gastric ulcer then repeat endoscopy and H.pylori test 6-8w later - +ve= second line H.pylori eradication - stop NSAIDs or aspirin - low dose PPI or standard-dose histamine (H2)-receptor antagonist as needed - can consider long-term acid suppression
470
471
Pt on long-term Mx for peptic ulcer disease should be...
- offered annual review - encouraged to step down or stop treatment if possible
472
Potential peptic ulcer inducing drugs?
aspirin, NSAIDs, bisphosphonates, corticosteroids, SSRIs, potassium supplements, cocaine
473
When to consider referral to gastro for peptic ulcer disease?
- refractory or recurrent symptoms despite Mx - unsuccessful second-line H.pylori erradication regimen - limited Abx options for H.pylori eradication therapy - proven gastric ulcer has not healed on repeat endoscopy - non-peptic cause of ulcer disease suspected
474
H.pylori test?
carbon-13 ura breath test or stool antigen test
475
What should pt do before H.pylori test?
do not take PPI 2w before or Abx 4w before
476
H.pylori eradication therapy?
Triple therapy 7d: 1) PPI: lansoprazole 30mg twice daily 2) Amoxicillin 1g twice daily 3) Clarithromycin 500mg or metronidazole 400mg twice daily allergic then PPI + clarithro + metron 2nd line therapy= use the Abx that wasn't used 1st
477
Peptic ulcer perforation CP?
- sudden epigastric pain, later more generalised - syncope
478
Ix for peptic ulcer perforation?
erect CXR if present with acute upper abdo pain= free air under diaphragm
479
Haemorrhoids? (piles)
abnormally swollen vascular mucosal cushions in anal canal
480
How are haemorrhoids classified?
internal or external depending on their origin in relation to dentate line
481
Where is the dentate line?
2cm from anal verge and marks the transition between the upper and lower anal canal
482
External haemorrhoids?
originate below the dentate line and covered by modified squamous epithelium (anoderm) which is richly innervated with pain fibres
483
Internal haemorrhoids?
arise above dentate line and covered by columnar epithelium, which have no pain fibres.
484
What haemorrhoids are itchy and painful?
external
485
What haemorrhoids are not sensitive to touch, temp or pain (unless become strangulated)?
internal
486
Internal haemorrhoids are further graded by degree of prolapse, what is 1st-4th degree?
1st degree= projects into lumen of anal canal but do not prolapse 2nd= prolapse on straining but reduce spontaneously when straining stopped 3rd= prolapse on straining and require manual reduction 4th= prolapsed and incarcerated and cannot be reduced
487
Factors thought to contribute to the development of haemorrhoids?
constipation straining while trying to pass stool ageing heavy lifting chronic cough conditions that cause raised intra-abdo pressure eg. preg, childbirth, space-occupying lesions
488
Cx of haemorrhoids?
ulceration, skin tags, maceration of perianal skin, ishaemia, thrombosis, gangrene rare= perianal sepsis and anaemia from bleeding
489
Potential serious underlying pathology of haemorrhoids?
colorectal ca
490
CP for haemorrhoids?
- bright red painless rectal bleeding seen as streaks on toilet paper, in toilet bowel and/or outside of stool (NOT MIXED) - anal itching & irritation - feeling of rectal fullness, discomfort or incomplete evacuation on bowel movement - soiling - anal pain (with prolapsed, strangulated interal H or thrombosed external H)
491
Mx for haemorrhoids?
- ensure stools soft & easy to pass (increase fibre and fluid intake) - laxatives if constipated - advice= minimise straining, good anal hygiene - simple analgesia and/or topical haemorrhoidal preparations
492
Admission or referral should be arranged for haemorrhoids if....
- diagnosis unclear - suspect serious pathology - severe - does not respond to conservative Mx - recurrent
493
Secondary care Mx for haemorrhoids?
- non-surgical= rubber band ligation, injection sclerotherapy, infrared coag/photocoagulation, biploar diathermy or direct-current electrotherapy - surgical= haemorrhoidectomy, stapled haemorrhoidectomy or haemorrhoidal artery ligation
494
Ix for haemorroids?
- clinical: exam-> inspect perianal area and perform digital rectal exam if possible without causing pain - rigid anoscope, proctoscope or rectoscope can be used to diagnose, classify and exclude sinister pathology
495
What analgesia to avoid in haemorrhoids?
- opioids as cause constipation - NSAIDs if rectal bleeding
496
Differential diagnosis of haemorrhoids?
- adenomatous polyps - anal fissure - anal or colorectal ca - rectal prolapse - STI - diverticular disease - anorectal fistula - IBD - perianal abscess - portal hypertension
497
Haemorrhoidal tissue is part of normal anatomy that contributes to anal continence, where are these mucosal vascular cushions found?
left lateral, right posterior and right anterior portions of anal canal (3, 7 and 11 oclock) haemorrhoids said to exist when become enlarged, congested and symptomatic
498
What haemorrhoids are prone to thrombosis?
external
499
Acutely thrombosed external haemorrhoids?
signif pain and tender lump; purplish, oedematous, tender subcut perianal mass. if present <72hrs then referal to consider excision; otherwise use stool softeners, ice packs and analgesia; symptoms settle within 10d
500
Hernia?
protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it
501
RFs for abdo wall hernias?
- obesity - ascites - ageing - surgical wounds
502
Features of abdo wall hernias?
- palpable lump - cough impulse - pain - obstruction (common in femoral hernias) - strangulation: may compromise bowel blood supply -> infarction
503
Types of abdo wall hernias? (9)
1) inguinal hernia 2) femoral 3) umbilical 4) paraumbilical 5) epigastric 6) incisional 7) spifelian 8) obturator 9) richter
504
Types of abdo wall hernias in children? (2)
1) congenital inguinal hernia 2) infantile umbilical hernia
505
Abdo wall hernia: inguinal?
75% of abdo wall hernias. 95% male. Men have 25% risk of developing. Above and medial to pubic tubercle; strangulation is rare.
506
Abdo wall hernia: femoral hernia?
Below and lateral to pubic tubercle. More common in women, espec multiparous ones. High risk of obstruction and strangulation/ Surgical repair required.
507
Abdo wall hernia: umbilical?
Symmetrical bulge under umbilicus.
508
Abdo wall hernia: paraumbilical?
asymmetrical bulge- half the sac is covered by skin of abdo directly above or below umbilicus
509
Abdo wall hernia: epigastric?
lump in midline between umbilicus and the xiphisternum. RFs= extensive physical training, coughing (from lung diseases) or obesity
510
Abdo wall hernia: incisional?
may occur in up to 10% abdo surgery
511
Abdo wall hernia: Spigelian?
AKA lateral ventral hernia. Older pts. Rare. Hernia though the spigelian fascia (aponeurotic layer between rectus abdominis muscle medially and semilunar line laterally).
512
Abdo wall hernia: obturator?
hernia which passes through obturator faroamen. more common in females. Typically presents with bowel obstruction.
513
Abdo wall hernia: Richter hernia?
rare only antimesenteric border of the bowel herniates through the fascial defect. Can present with strangulation WITHOUT symptoms of obstruction
514
Abdo wall hernia: congenital inguinal hernia?
Indirect hernia resulting from a patent processus vaginalis. 1% term babies; more common in premature babies and boys. 60% R sided, 10% bilateral. SURGICALLY REPAIR soon after diagnosis as at risk of incarceration.
515
Abdo wall hernia: infantile umbilical hernia?
Symmetrical bulge under umbilicus. More common in premature and Afro-Caribbean babies. Vast majority RESOLVE without intervention BEFORE 4-5yrs. Cx rare.
516
When do femoral hernias occur?
When section of bowel or any other part of abdo viscera pass into femoral canal.
517
Why can you get femoral hernias?
It is usually densely packed area of the anterior thigh but it is a potential space that can become occupied by herniated contents via the femoral ring.
518
Features of femoral hernia?
- lump within groin - mildly painful - important to distinguish from inguinal - typically non-reducible; can be reducible in minority - cough impulse ABSENT due to small size of femoral ring
519
Distinguish between femoral and inguinal hernia?
femoral= inferolateral to pubic tubercle inguinal= supermedial to pubic tubercle
520
Ix for femoral hernia?
- Diagnosis clinical, can use USS
521
Important differentials to exclude for femoral hernias?
- lymphadenpathy - abscess - femoral artery aneurysm - hydroccoele or varicocele in men - lipoma - inguinal hernia
522
Cx of femoral hernia?
- incarceration (herniated tissue can't be reduced) - STRANGULATION= emergency; tender, non-reducible; systemically unwell; increased risk as time from diagnosis rises and more likely than inguinal - bowel obstruction= emergency - bowel ischaemia and rescection -> high morbidity and mortality
523
Mx for femoral hernia?
- surgical remair NECESSITY due to risk of strangulation= laparoscopically or via laparotomy - hernia support belts/trusses should NOT be used as risk of strangulation
524
Features of inguinal hernia?
- groin lump superior and medial to pubic tubercle - disappears on pressure or when lying down - discomfort and ache: worse with activity but severe pain uncommon - strangulation RARE
525
Indirect vs direct inguinal hernia?
Indirect= hernia through inguinal canal Direct= through posterior wall of the inguinal canal
526
Mx for inguinal hernia
treat medically fit pts even if asymptomatic - mesh repair= open approach if unilateral; laparoscopic if bilateral or recurrent - hernia truss if not fit for surgery
527
Following open or laparoscopic mesh repair for inguinal hernia, how long before pt can return to work?
open= 2-3w L= 1-2w
528
Cx of inguinal hernia repair?
early= bruising, wound infection late= chronic pain, recurrence
529
What does it mean if a hernia is reducible?
herniated tissue can be pushed back into place in abdo through the defect using a hand
530
What is a hernia that cannot be reduced referred to as?
Incarcerated hernia: painless but at risk of strangulation
531
Strangulation of a hernia?
Surgical emergency where blood supply to herniated tissue compromised -> ischaemia or necrosis
532
What can a strangulated inguinal hernia (1/500) lead to?
permanent loss or perforation of bowel tissue as most inguinal hernias are formed from small bowel
533
Indications that a hernia is at risk of strangulation?
- episodes of pain in a hernia that was previously asymptomatic - irreducible hernia
534
CP of strangulated hernias?
pain; fever; increase in size of hernia or erythema of overlying skin; peritonitic features (guarding, tenderness); bowel obstruction (distension, N&V); bowel ischameia (bloody stools)
535
Is imaging necessary for strangulated hernia?
NO. But if obstruction suspected: abdo x-ray or CT. Perforation suspected then erect CXR. FBC and ABG= leukocytosis and raised lactate
536
What is it not recommended to do whilst waiting for surgery for strangulated hernia?
DO NOT manually reduce strangulated hernias as can cause more generalised peritonitis/
537
Mx for strangulated hernia?
immediate surgery= open or laparoscopic with mesh technique (like elective hernia repair) but also remove any dead bowel
538
Hiatus hernia?
herniation of part of the stomach above the diaphragm
539
2 types of hiatus hernia?
sliding and rolling
540
Sliding hiatus hernia?
95% gastroesophageal junction moves above the diaphragm
541
Rolling (paraoesophageal) hiatus hernia?
gastroesophageal function remains below the diaphragm but a separate part of the stomach herniates through the oesophageal hiatus
542
RFs for hiatus hernia?
obesity increased intraabdo pressure eg. ascites, multiparity
543
Features of hiatus hernia?
heartburn dysphagia regurgitation chest pain
544
Ix for hiatus hernia?
GOLD= barium swallow most sensitive but due to the CP most have endoscopy 1st line and hiatus hernia found incidentally
545
Mx for hiatus hernia?
- conservative eg. weight loss - medical: PPI - surgical: only in symptomatic paraesophageal hernias
546
Causes of hypospenism?
splenectomy sickle-cell coeliac dermatitis herpetiformis Grave's SLE amyloid
547
2 features of hyposplenism?
Howell-Jolly bodies and Siderocytes on blood film
548
What does the loss of splenic tissue following splenectomy result in?
inability to readily remove immature or abnorm RBCs from circulation; RBC count doesn't alter signif but cytoplasmic inclusions may be seen eg. Howell-Jolly bodies
549
What happens in the first few days after splenectomy and also immediately following?
Immediately= a granulocytosis (mainly composed of neutrophils) is seeen and this is replaced by a lymphocytosis and monocytosis over the following weeks. First few days after= target cells, siderocytes and reticulocytes will appear in circulation
550
Hyposplenism can result from splenic atrophy due to what?
certain conditions or interventions eg. splenic artery embolisation and splenectomy
551
Most sensitive diagnostic test for hyposplenism?
Radionucleotide-labelled red cell scan (Howell-Jolly bodies not fully reliable)
552
Risks associated with hyposplenism?
signif increases risk of post-splenectomy sepsis, espec from encapsulated organsims due to spleen's role in detecting and responding to these pathogens
553
What is crucial for prevention for post-splenectomy sepsis?
Vaccination and Abx prophylaxis. Asplenic pts should also use medical and mechanical protection when travelling to malaria-endemic areas.
554
Vaccination schedule used to prevent post-splenectomy sepsis?
- Men C and Hib at 2w post splenectomy (or 2w prior if elective) - MenACWY one month later - children <2yrs may need booster - Pneumococcal vaccine every 5yrs - Annual influenza
555
Abx prophylaxis for the prevention of post-splenectomy sepsis?
Penicillin V at least 2yrs and at least until pt is 16yrs. Majority usually for life.
556
Following splenectomy, pts are at particular risk from what infections?
pneumococcus, Haemophilus, meningococcus and Capnocytophaga canimorsus (dog bites)
557
Indications for splenectomy?
- trauma: 1/4 iatrogenic - spontaneous rupture: EBV - hypersplenism - malignancy: lymphome or leukaemia - splenic cysts, hydatid cysts, splenic abscesses
558
2 causes of hypersplenism?
hereditary spherocytosis or elliptocytosis
559
Elective splenectomy?
spleen often large Most laparoscopic Spleen will be macerated inside a specimen bag to facilitate extraction Prophylactic aspirin
560
Cx of splenectomy?
- haemorrhage (from short gastrics or splenic hilar vessels) - pancreatic fistula (from iatrogenic damage to pancreatic tail) - thromocytosis (so prophy aspirin) - Encapsulated bacteria infection eg. strep. pnuemoniae, H. influenzae and Neisseria meningitidis
561
Post-splenectomy changes?
- platelets will rise first (so ITP given after splenic artery clamped) - blood film will change over weeks, Howell-Jolly bodies appear - other blood film changes: target cells and Pappenheimer bodies - increased risk of post-splenectomy sepsis
562
Campylobacter?
Commonest bacterial cause of infectious intestinal disease
563
What is campylobacter infection caused by?
Gram negative baciluus Campylobacter jejuni
564
How is campylobacter spead and incubation period?
faecal-oral route 1-6 days
565
Features of campylobacter infection?
- prodrome= headache, malaise - diarrhoea= often bloody - abdo pain= may mimic appendicitis
566
Mx for campylobacter infection?
- self-limiting - Abx if immunocompromised or severe: high fever, bloody diarrhoea, >8 stools per day, lasted >1w clarithromycin first line
567
Cx of campylobacter infection?
- Guillain-Bare - Reactive arthritis - Septicaemia, endocarditis, arthritis
568
What type of bacteria is Clostridioides difficile?
Anaerobic gram positive rod, spore-forming, toxin-producing bacillus
569
What does c.diff produce?
an exotoxin which causes intestinal damage leading to pseudomembranous colitis
570
When does C.difficile develop?
when normal gut flora are suppressed by broad-spectrum Abx
571
What causes C.difficile?
- 2nd & 3rd gen cephalosporins (main) - clindamycin - PPI
572
What is characteristic in c.diff?
raised WCC
573
Pathophysiology of c.diff?
releases 2 exotoxins (toxin A and B) that act on intestinal epithelial cells and inflam cells resulting in colitis
574
How is c.diff transmitted?
faecal-oral route by ingestion of spores
575
Features of c.diff?
- diarrhoea - abdo pain - raised WCC - if severe toxic megacolon may develop
576
Mild c.diff?
normal WCC
577
Moderate c.diff?
↑ WCC ( < 15 x 109/L) Typically 3-5 loose stools per day
578
Severe c.diff?
↑ WCC ( > 15 x 109/L) or an acutely ↑ creatinine (> 50% above baseline) or a temperature > 38.5°C or evidence of severe colitis(abdominal or radiological signs)
579
Life-threatening c.diff?
Hypotension Partial or complete ileus Toxic megacolon or CT evidence of severe disease
580
Diagnosis of c.diff?
- Detecting C.diff toxin (CDT) in stool
581
What only shows c.diff exposure to the bacteria rather than current infection?
C.diff antigen c.diff toxin= current
582
Mx of first episode of c.diff infection?
1st: oral vancomycin 125mg 4x day 10days or 2nd: oral fidaxomicin 200mg 2x day for 10d or 3rd: oral vancomycin +/- IV metronidazole
583
Mx of recurrent episodes of c.diff? (20% pts, after 2nd episode its 50%)
- within 12w of symptom resolution= oral fidaxomicin - after 12w of symptom resolution= oral vancomycin OR fidaxomicin
584
Mx for life-threatening c.diff infection?
oral vancomycin AND IV metronidazole also specialist advice as may need surgery
585
What may be considered for pts who have had 2 or more episodes of c.diff?
faecal microbiota transplant
586
Prevent spread of c.diff?
- isolation in side room until no diarrhoea (types 5-7 Bristol Stool chart) for at least 48hrs - PEE if contact with pt with c.diff (gloves and apron) - hand washing as alcohol gel does not kill c.diff spores
587
What meds should you review the need to continue if pt has c.diff?
avoid antimotility drugs eg. loperamide and if possible any with anti-peristaltic effect eg. opiods. review... - PPI - laxatives - meds that cause problems if pt dehydrated eg. NSAIDs, ACEi, ARB, diuretics
588
Advise to give pt with C.diff?
- diarrhoea should resolve 1-2w - not usually possible to determine if Abx effective until day 7 - remain infectious while ill and have symptoms - DO NOT return to school/work until no diarrhoea for >48hrs refer to hospital if severe
589
Gastroenteritis?
transient disorder due to enteric infection, usually caused by viruses, characterised by sudden onset diarrhoea with or without vomiting
590
Food poisoning?
an illness caused by consumption of food or water contaminated with bacteria and/or their toxins, or with parasites, viruses or chemicals
591
Acute diarrhoea?
3+ episodes of liquid or semi-liquid stool in 24hr period, lasting for <14d where stool takes the shape of the sample pot
592
Prolonged diarrhoea?
acute-onset diarrhoea that has persisted for >14d
593
Most infectious diarrhoea is a.... illness
self-limiting
594
Transmission of infectious diarrhoea?
faecal-oral, foodborne, environmental, airborne
595
Cx of gastroenteritis?
dehydration, electrolyte disturbance, AKI, sepsis, haemolytic uraemic syndrome, secondary irritable syndrome, IBS
596
What to ask pt with symptoms of gastroenteritis?
- diarrhoea (blood, mucus, pus); N; V; abdo pain; fever; malaise - onset, freq, duration - RFs for developing dehydration eg. co-morbid conditions, fluid & food intake, urine output - recent food intake - recent exposure to other cases or outbreaks - recent foreign travel or hospital admission - recent drug treatment
597
Ix for gastroenteritis/diarrhoea?
- clinical - stool culture and sensitivity if indicated
598
When would you do a stool culture and sensitivity for pt with gastroenteritis/diarrhoea?
- systemically unwell or possible dysentery (acute painful diarrhoea or blood, mucus or pus in stool) - prolonged diarrhoea - recent travel - contact with affected person or outbreak
599
Mx for gastroenteritis?
- advise on how to monitor fluid intake & prevent/treat dehydration= oral rehydration salt solution - Abx, anti-diarrhoeal, anti-emetic and probiotic NOT recommoneded routinely - hygiene to prevent transmission - notify public health if notifiable disease - liase with microbio if specific cause confirmed- need for Abx and/or stool testing for microbio clearance - emergency admission if needed
600
Traveller's diarrhoea?
gastroenteritis when travelling abroad. 3 or more loose to watery stools with or without one or more of: abdo cramps, fever, V or blood in stool
601
Most common cause of travellers diarrhoea?
Escherichia coli
602
Most common cause of acute food poisoning?
Staph aureus, Bacillus cereus, or clostridium perfringens
603
Typical presentation for infection with E.coli?
common among travellers watery stools abdo cramps and nausea
604
Typical presentation for infection with Giardiasis?
prolonged non-bloody diarrhoea
605
Typical presentation for infection with Cholera?
profuse watery diarrhoea severe dehydration resulting in weight loss not common amongst travellers
606
Typical presentation for infection with Shigella?
bloody diarrhoea vomiting and abdo pain
607
Typical presentation for infection with Staph. aureus?
severe vomiting short incubation period
608
Typical presentation for infection with Campylobacter?
flu-like prodome followed by crampy abdo pain, fever and diarrhoea which may be bloody. may mimic appendicitis Cx= Guillain-Bare
609
Typical presentation for infection with Bacillus cerus?
2 types of illness seen: 1) vomiting within 6hrs, stereotypically due to rice that has been reheated 2) diarrhoeal illness after 6hrs
610
Typical presentation for infection with Amoebiasis?
gradual onset bloody diarrhoea, abdo pain and tenderness which may last several weeks
611
Gastroenteritis is typically caused by infection with what?
E.coli, Giardiasis, Cholera, Shigella, Staph. aureus, Campylobacter, Bacillus cereus, Amoebiasis or Salmonella
612
Gastroenteritis causes: what has an incubation period of 1-6hrs?
staph aureus and Bacilus cereus (Vomiting subtype, diarrhoeal illness is 6-14hrs)
613
Gastroenteritis causes: what has an incubation period of 12-48hrs?
Salmonella, E.coli
614
Gastroenteritis causes: what has an incubation period of 48-72hrs?
Shigella, Campylobacter
615
Gastroenteritis causes: what has an incubation period of >7d?
Giardiasis, Amoebiasis
616
Advice to monitor fluid intake and prevent/treat dehydration for pts with gastroenteritis?
- regular fluid intake - oral rehydration salt solution: small amounts eg. 200-400ml after every loose motion
617
What to do if pt with gastroenteritis has a specific microbio cause confirmed after stool culture and sensitivity testing in gastroenteritis?
advice from local health protection team regarding need to Abx Mx or stool testing for microbio clearance if any uncertainty
618
When to urgently admit pt with gastroenteritis to hospital?
systemically unwell and/or features suggesting severe dehydration and/or progression to shcok intractable vomiting or high-ouput diarrhoea suspect sepsis
619
The Salmonella group contains many members, most cause what? What are they?
diarrhoeal disease. Aerobic gram -ve rods which not normally present as commensals in the gut
620
What are Typhoid and paratyphoid caused by and CP?
Typhoid= Salmonella typhi Parathoid= Salmonella paratyphi (types A, B,C) Termed enteric fevers causing headache, fever, arthralgia
621
Serotypes of Salmonella that are relatively common causes of bacterial gastroenteritis? Features
Salmonella enteritidis and Salmonella typhimurium. Source= poultry eg. chicken or eggs CP: diarrhoea, N&V, abdo cramps, fever, lethargy
622
When to urgently admit child with gastroenteritis to hospital?
- systemically inwell - severe dehydration - progressing to shock - acute-onset painful blood diarrhoea in previously healthy child - intractable or biliouis vomiting - ?sepsis - clinically deteriorating - unable to take or no response to ORS
623
When does diarrhoea and vomiting usually resolve in children with gastroenteritis?
D= lasts 5-7d, stops within 2w V= lasts 1-2d, stops within 3d
624
Fluid volume requirement to maintain hydration in children? (eg. in gastroenteritis)
0-10kg= 100mL/kg fluids per day 10-20kg= 1000mL + 50mL/kg for each kg over 10kg per day >20kg= 1500mL + 20mL/kg for each kg over 20kg per day
625
How much to give child eg. with gastroenteritis if using low-osmolarity oral rehydration salt (ORS) solution to rehydrate a child (240-250mOsm/L)?
5yrs or young= 50mL/kg for fluid deficit + maintenance volume of ORS solution over 4hrs. Breastfeeding can continue but no other fluids. 5-11yrs= 200mL ORS after each stool in addition to normal fluid intake 12-16yrs= 200-400mL ORS solution after every loose stool, dose according to fluid loss after rehydration, for children at increased risk of dehydration= 5mL/kg body weight after each large watery stool
626
Shigella?
causes diarrhoea (may be bloody), abdo pain usually self-limiting and doesn't need Abx severe/immunocompromised/bloody diarrhoea= ciprofloxacin
627
What does severity of Shigella depend on?
type S sonnei (from UK) may be mild but S.flexneri or S.dysenteriae from abroad may cause severe
628
Crohn's?
chronic, relapsing-remitting, non-infectious, inflam disease of the GI tract
629
Where does the inflam in crohn's affect?
discrete parts of the GIm anywhere from mouth to anus, and affects the full thickness of the intestinal wall
630
Extra-intestinal manifestations of crohn's (20% of pts)? May be present before GI symptoms.
- pauci-articular arthritis (<5 joints): asymmetric and self-limiting (w not m) - erythema nodosum - apthous mouth ulcers - episcleritis - metabolic done disease: osteopenia, porosis and malacia
631
RFs for Crohn's?
immune-mediated condition caused by environmental triggering events in genetically susceptible people: - FHx IBD - smoking - previous infectious gastroenteritis - NSAIDs
632
Cx of crohn's?
- psychosocial impact - abscesses - strictures - fistulas - anaemia - malnutrition - faltering growth and delayed puberty - cancer of small & large bowel
633
CP of crohn's?
- persistent diarrhoea 4-6w (incl nocturnal) with possible blood or mucus - abdo pain - fatigue, malaise, anorexia, fever - pallor, clubbing - apthous mouth ulcers - abdo tenderness or mass eg. LRQ - perianal pain, anal or perianal skin tags, fissure, fistula or abscess - signs of malnutrition and malabsorption (weight loss) - abnorm. of joints, eyes, liver and skin
634
Emergency admission for crohn's?
systemically unwell & blood diarrhoea, fever, tachy or hypotension
635
Follow up in primary care for Crohn's?
- lifestyle and support: lifelong condition, stop smoking - osteoporosis risk - follow-up with gastro specialist (Mx always initiated by specialist) - assess for relapse: BMI, CRP - refer to appropriate specialist if extra-intestinal manifestations - advice about vaccines: influenzae and pnuemococcal - referral for pre-conception planning if needed
636
CP in crohn's colitis?
faecal urgency, tenesmus (desire to defecate while passing no or little stool), and blood or mucus. More likely to have extra-intestinal manifestations compared to other areas of GI involement
637
Ix for crohn's in primary care?
- FBC: anaemia due to blood loss, increased platelet - CRP and ESR - U&Es: ?dehydration & electro distrub - LFTs: albumin - Ferritin, B12 folate vit D - Coeliac serology - Stool microscopy and culture: ?c.diff - faecal calprotectin: raised with active inflam may be normal
638
Ix for crohn's?
- bloods and stool sample in primary care then refer to specialist to confirm: - Colonoscopy and biopsy - Upper intestinal endoscopy if upper GI tract symptoms
639
What does colonoscopy and histology of intestinal biopsy show? (6)
- Skip lesions - deep ulcers - Cobblestone appearance - Goblet cells - Inflammation in all layers from mucosa to serosa - Granulomas - Rectal sparing allows to classify severity
640
Mx of crohn's? (specialist)
- induce remission= glucocorticoids - 2nd= 5-ASA drugs eg. mesalazine - infliximab useful in refractory disease and fistulating; metronidazole often used for isolated peri-anal disease - maintaining remission= azathioprine or mercaptopurine - 2nd= methotrexate - surgery
641
Monitoring of crohn's?
serum ferritin, B12, folate, calcium and vit D
642
Where does crohn's commonly affect?
terminal ileum and colon
643
Why are pts with Crohn's prone to strictures, fistulas and adhesions?
inflamm occurs in all layers, down to the serosa
644
When does crohn's typically present?
late adolescence or early adulthood
645
What would a small bowel enema (high sens and spec for exam of terminal ileum) show in crohn's?
- strictures: Kantor's string sign - proximal bowel dilation - Rose thorn ulcers - Fistulae
646
1st line drugs to induce and then maintain remission in Crohn's?
induce= glucocorticoids eg. pred maintain= azathioprine or mercaptopurine
647
What must be assessed in pts before starting azathioprine or mercaptopurine to maintain remission in crohn's?
TPMT activity (thiopurine methyltransferase activity)
648
Surgery for crohn's? (80% pts will eventually have)
- stricturing terminal ileal disease= ileocaecal resection - segmental small bowel resections - stricturoplasty - perianal abscess: incision and drainage + Abx - draining seton for complex perianal fistulae
649
Perianal fistulae in Crohn's?
- inflam tract or connection between anal canal & perianal skin - MRI GOLD for suspected fistulae -Mx= oral metronidazole; anti-TNF eg. infliximab may also be effective - complex= draining seton
650
Common extra-intestinal features of CD and UC related to disease activity?
Arthritis: pauciarticular, asymmetric Erythema nodosum Episcleritis Osteoporosis
651
Common extra-intestinal features of CD and UC unrelated to disease activity?
Arthritis: polyarticular, symmetric Uveitis Pyoderma gangrenosum Clubbing Primary sclerosing cholangitis
652
Crohn's vs Ulcerative colitis features?
CD= diarrhoea usually NON-BLOODY (except crohns colitis); weight loss prominent; upper GI symptoms: mouth ulcers; perianal disease; abdo mass palpable in right iliac fossa UC= BLOODY diarrhoea more common; abdo pain in left lower quadrant; tenesmus
653
Crohn's vs Ulcerative colitis extra-intestinal features?
CD= gallstones more common (oxalate renal stones) secondary to reduced bile acid reabsorption. UC= primary sclerosing cholangitis more common
654
Why are gallstones more common in CD?
oxalate renal stones impaired bile acid rebsorption increases loss of calcium in bile. Calcium normally binds to oxalate.
655
Cx of crohn's vs ulcerative colitis?
CD= obstruction, fistula, colorectal ca UC= risk of colorectal ca higher
656
Pathology of crohn's vs ulcerative colitis?
CD= SKIP LESIONS may be present; can be seen anywhere from mouth to anus. UC= continuous disease; inflam always starts at rectum and never spreads beyond ileocaecal valve.
657
Crohn's vs ulcerative colitis endoscopy (colonoscopy)?
CD= deep ulcers, skin lesions, cobblestone appearance UC= widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (pseudopolyps)
658
CD vs UC radiology?
CD= small bowel enema UC= barium enema
659
Role of smoking in CD vs UC?
Smoking an increase risk of developing CD and can make it worse. Smoking protective factor in US: less likely to develop UC and stopping smoking increases risk of UC.
660
Ulcerative colitis?
Chronic, relapsing-remitting, non-infectious inflam disease of GI tract
661
UC is characterised as what?
diffuse, continuous, superficial inflam of large bowel, limited to intestinal mucosa, and usually affects the rectum with a variable length of the colon involved proximally
662
Extra-intestinal manifestations of UC?
uveitis, inflam arthritis, erythema nodosum and pyoderma gangrenosum
663
IBD?
UC and CD sometimes can differentiate histologically between 2= IBD type unclassified
664
Pathophysiology of UC?
exact unknown immune-mediated condition resulting in impaired epithelial barrier function and chronic inflam caused by envrionmental triggers eg. changes in gut microbiome in genetically susceptible people
665
Cx of UC?
psychosocial impact, toxic megacolon and bowel obstruction, anaemia, malnutrition, growth failure and colorectal cancer
666
CP of UC?
bloody diarrhoea >6w, rectal bleeding, faecal urgency and/or incontinence, nocturnal defecation, tenesmus, abdo pain, pre-defecation pain relieved on passage of stool, weight loss, fatigue, malaise, fever. Pallor, clubbing, abdo distension, tenderness or mass.
667
Ix for UC?
- FBC, CRP & ESR, U&Es, LFTs, TFTs, ferritin, B12, folate, vit D, coeliac serology - stool microscopy and culture incl. c.diff toxin and faecal calprotectin - urgent referral to gastro specialist to confirm diagnosis
668
Regular review in primary care for UC?
- support and advice - osteoporosis risk - follow up with specialist if appropriate - monitoring - assess for flare-up - refer to appropriate specialist if E-I manifestations or to stoma nurse, dietitian or colorectal surgeon - vaccinations - advice to be referred to gastro if planning pregnancy to ensure optimal disease control
669
Specialist Ix for UC?
colonoscopy with biopsy if severe colitis, AVOID colonoscopy due to risk of perforation= use flexible sigmoidoscopy barium enema if colonoscopy can't be performed due to strictures or difficult accessibility may do upper intestinal biopsy to differentiate from Crohn's
670
Macroscopic features of UC on colonoscopy?
- red, raw mucosa, bleeds easily - no inflammation beyond submucosa - pseudopolyps (widespread ulceration with preservation of adjacent mucosa which has appearance of polyps)
671
Histology findings of UC?
- crypt distorsion - crypt abscesses - inflam cells infiltrate in lamina propria - depletion of goblet cells - infrequent granulomas
672
Mx for UC?
Mild-moderate= topical (rectal) aminosalicylates (mesalazine and sulfasalazine), if admission not within 4w then add an oral aminosalicylate. Oral + topical if extensive. 2nd line= corticosteroids Acute-severe= IV steroids; if no improvement >72hrs then + IV ciclosporin Maintain remission= - topical (rectal) (+oral if severe) aminosalicylate daily or intermittent - if >=2 flares in past year and severe relapse= oral azathioprine or oral mercaptopurine - biologics eg. infliximab can be used in severe
673
Severity tool used in UC?
Truelove and Witts' (adults) Paediatric Ulcerative Colitis Activity Index (children)
674
Laxative for constipation in UC?
bulk-forming eg. ispaghula husk or methylcellulose
675
Avoid what in UC and CD?
NSAIDs- may make symptoms worse
676
Type of inflammation in UC?
always starts in rectum, never spreads beyond ileocaecal valve and is continuous
677
Most common site for UC?
rectum
678
Peak incidence for UC?
15-25yrs and 55-65yrs
679
Region of abdo pain in CD vs UC?
CD= RIF UC= LIF
680
What forms crypt abscesses in UC?
neutrophils migrate through the walls of glands to form them
681
Barium enema in UC?
- loss of haustrations - psuedopolyps- superficial ulceration - long standing disease: colon is narrow and short- drainpipe colon
682
Risk of what type of cancer is high in UC?
colorectal due to chronic inflam. Worse prognosis due to delayed diagnosis. lesions may be multifocal
683
Factors in UC that increase risk of colorectal ca?
- disease duration >10yrs - pancolitis - onset <15yrs - unremitting disease - poor Mx compliance
684
What should be decided to be done following risk stratification in IBD pts?
Colonoscopy surveillance for colorectal ca
685
Colonoscopy surveillance for pts with IBD low risk for ca?
5yr follow up - extensive colitis with no endoscopic/histo inflam - OR left sided colitis - OR crohn's colitis <50% of colon
686
Colonoscopy surveillance for pts with IBD intermediate risk for ca?
3yr follow up - extensive colitis with mild active endo/histo inflam - OR post-inflam polyps - OR FHx of colorectal ca in 1st degree relative aged 50yrs+
687
Colonoscopy surveillance for pts with IBD high risk for ca?
1yr follow up - extensive colitis with moderate/severe active endo/histo inflam - OR stricture in past 5yrs - OR dysplasia in past 5yrs declining surgery - OR primary sclerosing cholangitis/transplant for primary sclerosing cholangitis - OR FHx of colorectal ca in 1st degree relative aged 50yrs+
688
Factors that may trigger flares in UC?
- stress - meds: Abx, NSAIDs - stopping smoking
689
Irritable bowel syndrome? (IBS)
chronic, relapsing and often debilitating disorder of gut-brain interaction
690
CP of IBS?
abdo pain associated with: - change in stool form and/or frequency - may be related to defaecation and bloating
691
Pathophysiology IBS?
not understood ?multifactorial: bio, psysch and social factors
692
Prevalence of IBS?
5-20%
693
When to suspect IBS? (ABC)
>6m of: - abdo pain or - bloating or - change in bowel habit - may be relieved by defecation - altered bowel frequency and stool form (hard, lumpy, loose, watery) at least 2 of: - altered stool passage (straining, incomplete evac or urgency) - abdo bloating, distension, tension or hardness - made worse by eating - passage of mucus
694
Diagnosis of IBS?
diagnosis of exclusion - clinical - Ix to rule out other: FBC, ESR & CRP, coeliac serology, faecal calprotectin
695
Inital Mx for IBS?
- explanation: gut-brain axis - balanced diet, adjust fibre, adequate fluids - exercise - manage associated stress ect.
696
Medical Mx for IBS if dietary and lifestyle advice doesn't work?
- Constipation= laxatives but avoid lactulose - Diarrhoea= loperamide - Abdo pain/spasm= antispasmodic eg. mebecerine - Refractory abdo pain= low dose tricyclic or SSRI 2nd line
697
Referral for IBS?
Gastro: - uncertain - atypical, severe, refractory Mental health: - >12m and/or psycho cormorbities
698
Red flag symptoms in IBS?
weight loss, rectal bleeding, positive faecal immunochemical test (FIT), change in bowel habit >60yrs, iron def anaemia, abdo or rectal mass
699
ROME IV criteria for IBS (for diagnosis in secondary care)?
recurrent abdo pain, >=1 per week in last 3m (onset 6+m prior to diagnosis and associated with 2+: - related to defaecation - change in frequency of stool - change in stool form
700
Sub-groups of IBS?
based on britsol stool type... IBS-D (with diarrhoea) IBS-C (constipation) IBS-M (both) IBS-U (unclassified: don't fall into the other criteria)
701
Differential diagnosis for IBS?
- malignancy (colorectal, small bowel, ovarian, lymphoma) - PMS and endo - anxiety/depression Constipation: - functional or drug-induced - hypothyroidism Diarrhoea: - IBD - Coeliac - GI indection and secondary lactose intol - Abx associated - hyperthroid - microscopic colititis - bile acid malabsorption - laxative misuse Abdo pain/discomfort: - diverticular disease - chronic pancreatitis - gallstones - peptic ulcer disease - GORD
702
Malnutrition?
state in which a def of nutrients eg. energy, protein, vitamins and minerals causes measurable adverse effects of body composition, function or clinical outcome. Both a cause & consequence of ill health/
703
Nutrition support be considered in people who are malnourished, how is this defined?
- BMI <18.5kg/m2 - unintentional weight loss >10% within last 3-6m - BMI <20 and unintentional weight loss >5% within last 3-6m
704
Nutrition support should be considered in people at risk of malnutrition, defined as what?
- eaten little or nothing for >5d and/or likely to eat little or nothing for the next 5d+ - poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs
705
Reasons for malnutrition?
- acute illness - frailty - ageing - appetite - eating & swallowing difficulties - neuro disease - chronic conditoons - psychological - socioeconomic
706
Cx of malnutrition?
increased vulnerability to infection and disease, reduced wound healing, pressure ulcers, frailty, falls, reduced function, anxiety, depression, cognitive impairment, social & healthcare costs
707
When should people be screened for malnutrition?
- initial registration at GP - routine health checks and immunisations - med reviews - contact with community/district nurse - admission to new care setting eg. care home - clinical concern
708
What may cause clinical concern for malnutrition?
- unintentional weight loss - apathy or fatigue - poor appetite; early satiety; altered taste; diff swallowing - altered bowel habit - recurrent infection or prolonged intercurrent illness - reduced physical function - frequent falls - thin; sarcopenia; loose-fitting clothes, jewllery or dentures - fraile skin - poor wound healing - pressure ulcers
709
Assessment of pt with or at risk of malnutrition?
- ask: nut intake; unintent weight loss; energy; strength; activity levels; swallowing or appetite issues; mood/cognitive changes; GI sympt; drugs, alcohol, social situation - exam: BMI; trend in weight loss; signs of malnutrition, acute illness and dehydration; mobility and muscle strength - consider baseline bloods
710
Mx of pt with or at risk of malnutrition?
- nutritional care plan, dietary advice and nutrition support - manage underlying conditions - set individual goals - oral nut supplementation if clinically indicated - refer to dietitian, SALT, occy therapist, physio, mental health or adult social care if indicated - monitor progress 1-3m
711
Screening tool for malnutrition?
Malnutrition Universal Screen Tool Includes: BMI, recent weight change and presence of acute disease low, medium or high risk eg. done on admission to hospital or care/nursing homes or if concern eg. thin elderly pt with pressure sores
712
Dietary advice for malnutrition?
- small frequent meals of nutrient rich foods and drinks - considered powdered nut supp to be made up with milk - food first approach: eg. full fat cream added to mash; before prescribing oral nutritional supplements (ONS) eg. Ensure - if ONS used then take between meals not instead of
713
Necrotising enterocolitis?
one of leading causes of death in premature infants tissues in bowel become inflamed and start to die, can lead to perforation, sepsis, death
714
RFs for necrotising enterocolitis
prematurity low birth weight formula feeding
715
CP of necrotising enterocolitis?
typically 2-3rd week of life - feeding intolerance - abdo distension - bloody stools can quickly progress to - abdo discolouration - perforation - peritonitis
716
Diagnosis of necrotising enterocolitis?
Abdo x-ray
717
Abdo x-ray findings for necrotising enterocolitis?
- dilated bowel loops (asymmetrical) - bowel wall oedema - pneumatosis intestinalis (intramural gas) - portal venous gas - pneumoperitoneum resulting from perforation - Rigler sing - football sign
718
Rigler sign and football sign on abdo x-ray for necrotising enterocolitis?
Rigler= air both inside and outside bowel Football= air outlining falciform ligament
719
Mx for necrotising enterocolitis?
Prophy= antenatal steroids if premature delivery anticipated Medical (if stage I or II, not III)= withhold oral feeds and replace with parenteral for 10-14d; IV Abx 10-14d; systemic support eg. ventilatory support, fluid resus Surgical (perforation, obstruction or deterioration)= intestinal resection with stoma formation
720
Perianal abscess?
collection of pus within subcut tissue of anus that has tracked from the tissue surrounding anal sphincter more common in men average age is 40yrs
721
Most common anorectal abscess (60%)?
Perianal abscess
722
Features of perianal abscess?
- pain around anus, worse on sitting - hardened tissue in anal region - pus-like discharge from anus - if longstanding= systemic infection
723
Causes of perianal abscess?
- colonised by gut flora eg. E.coli - if staph aureus then more likely infection of skin rather than GI tract
724
Ix for perianal abscess?
- inspection and digital rectal exam - if uncertain= colonoscopy, bloods (CRP & ESR; cultures) GOLD= transperineal USS but rarely used unless it has Cx or part of more serious condition eg. IBD
725
Perianal abscess associated conditions?
- can be caused by IBD espec crohn's - DM (due to ability to affect wound healing) - malignancy
726
Mx for perianal abscess?
1st= surgical incision and drainage under local; wound then packed or left open and will heal in 3-4w - Abx if systemic infection
727
Types of anorectal abscess?
- Perianal= simple abscess of subcut tissue - Ischiorecal= between obturator internus muscles and external anal sphinter - Supralevator= when infection tracks superiorly from peri-sphincteric area to above levator ani - Intersphincteric= rare; between internal and external anal sphincters - Horseshoe= in potential space between coccyx and anal canal in pelvis; can be result of Cx from another anorectal abscess eg. SL
728
Secondary peritonitis?
Inflam condition of peritoneum, usually due to spillage of GI or biliary contents into peritoneal cavity.
729
Secondary peritonitis is frequently precipitated by what?
the perforation of a visceral organ eg. stomach, intestines or gallbladder
730
Common causes of secondary peritonitis?
- perforated peptic ulcer - ruptured appendicitis - diverticulitis - GI tract perforations that are secondary to trauma or neoplasia
731
Pathophysiology of secondary peritonitis?
Breach of GI tract integrity -> contam of sterile peritoneal environment -> inflam response= activation of innate immune system, recruitment of neutrophils and release of pro-inflam cytokines.
732
Severity of secondary peritonitis depends on what?
nature and amount of contaminating material as well as host's immune response
733
CP of secondary peritonitis?
- acute severe abdo pain - localised to site of pathology - pain may become more diffuse as inflam spreads across peritoneum - fever, tachy, signs of peritoneal irritation (rebound tenderness and guarding)
734
Signs of peritoneal irriation eg. in peritonitis?
rebound tenderness and guarding
735
What may develop in severe cases of secondary peritonitis?
System inflam response syndrome (SIRS) potentially progressing to septic shock
736
Diagnosis of secondary peritonitis?
- primarily clinical and supported by... - abdo x-ray= pneumoperitoneum if GI perforation - USS & CT= more sensitive for intra-abdo abscesses and delineating the extent of inflam - Bloods= leukocytosis and raised CRP
737
Mx for secondary peritonitis?
- Urgent surgery + broad spectrum Abx - Abx should cover common intra-abdo pathogens eg. gram negative bacilli and anerobic bacteria surgery examples= appendectomy, repair of perforated ulcers, resection of necrotic bowel segments
738
Spontaneous bacterial peritonitis? (SBP)
form of peritonitis usually seen in pts with ascites secondary to liver cirrhosis
739
Features of spontaneous bacterial peritonitis?
ascites, abdo pain and fever
740
Diagnosis of spontaneous bacterial peritonitis?
- paracentesis= neutrophil >250 cells/ul - most common organism found on ascitic fluid culture= E/coli
741
Mx of spontaneous bacterial peritonitis?
IV cefotaxime
742
When should Abx prophylaxis be given to pts with ascites (to prevent spontaneous bacterial peritonitis)?
oral ciproflocacin or norfloxacin - previous episode of SBP - fluid protein =<15g/l and either hepatorenal syndrome or Child-Pugh score of 9+ - Pt with cirrhosis and acites with ascitic protein 15g/l or less until ascites has resolved
743
What is a marker of poor prognosis in SBP (spontaneous bacterial peritonitis)?
alcoholic liver disease
744
Primary biliary cholangitis?
or primary biliary cirrhosis Chronic liver disorder typically seen in middle aged females. Interlobular bile ducts become damaged by a chronic inflam process causing progressive cholestasis which may progress to cirrhosis. Autoimmune.
745
Itching middle-aged women?
Primary biliary cholangitis
746
Primary biliary cholangitis associations?
Sjogren's syndrome (80%) RA systemic sclerosis thyroid
747
CP of primary biliary cholangitis?
Early: asymptomatic (raised ALP on routine LFTs) or fatigue and pruritus - cholestatic jaundice - hyperpigmentation, espec over pressure points - 10% have RUQ pain - xanthelasmas, xanthomata - clubbing hepatosplenomegaly Late: may progress to liver failure
748
Diagnosis of primary biliary cholangitis?
- Immunology= anti-mitochondrial antibodies (AMA) M2 subtype (v specific and 98% pts); smooth muscle antibodies (30%) and raised serum IgM - Imaging- RUQ USS OR MRCP= BEFORE DIAGNOSIS to exclude extrahepatic biliary obstruction
749
Mx for primary biliary cholangitis?
1st= ursodexoxycholic acid - Pruritis= cholestyramine - Fat-soluble vit supplements Liver transplant: PBC or also if eg. bilirubin >100; can get recurrence in graft but not common
750
Role or ursodeoxycholic acid in primary biliary cholangitis?
slow disease progression and improves symptoms
751
Cx of primary biliary cholangitis?
- cirrhosis -> portal HTN -> ascites, variceal haemorrhage - osteomalacia and osteoporosis - signif increased risk of hepatocellular carcinoma
752
Role of vit B12?
RBC development and maintenance of NS.
753
Absorption of vit B12?
binds to intrinsic factor and actively absorbed in terminal ileum; small amount passively absorbed without being bound to intrinsic factor
754
Where is intrinsic factor secreted?
Parietal cells in stomach
755
Role of intrinsic factors?
binds to vit B12 so B12 can be absorbed in terminal ileum
756
Causes of vit B12 def?
- pernicious anaemia (most common) - post gastrectomy - vegan or poor diet - disorders/surgery of terminal ileum eg. Crohn's disease activity or following ileocaecal resection - metformin (rare)
757
Features of vit B12 def?
- macrocytic anaemia - sore tongue and mouth - neuro symptoms= dorsal column usually affected first (joint position, vibration) prior to distal paraesthesia - neuropsychiatric symptoms eg. mood disturbances
758
Mx of vit B12 def?
- if no neuro invl= 1mg IM hydroxocobalamin (B12) 3x each week for 2w, then once every 3m TREAT B12 def BEFORE FOLIC ACID def
759
What if pt is folic acid def and B12 def?
Treat B12 def first to avoid precipitating subacute combined degeneration of the cord
760
Where can abdo pain originate?
- abdo wall - stomach - liver - gallbladder - spleen - pancreas - kidneys - intestines - reproductive organs
761
What does innervation of abdo organs involve?
Somatic and visceral nerve which contribute to nature and perception of pain
762
Differential diagnosis of abdo pain? (incl medical & unusual)
- peptic ulcer disease - appendicitis - acute pancreatitis - biliary colic - acute cholecystitis - AAA - intestinal obstruction Medical and unusual causes: - ACS - DKA - pneumonia - acute intermittent prophyria - lead posioning
763
Type of abdo pain in peptic ulcer disease?
Duodenal (more common)= epigastric pain relieved by eating Gastric= epigastric pain worsened by eating - Features of upper GI haemorrhage may be seen (haematemesis, melena)
764
Type of abdo pain in appendicitis?
- initial in periumbilical region then localises to RIF - Robsing's sign= more pain in RIF than LIF when palpate LIF - tachy, low-grade pyrexia, tenderness in RIF
765
Type of abdo pain in acute pancreatitis?
- severe epigastric pain - may radiate to back - usually due to alcohol or gallstones - vomiting, ileus, low grade fever - Cullen's and Grey-Turner's sign but rare
766
Ileus?
temp and often reversible cessation of bowel movements and peristalsis, can lead to functional obstruction. causes= post-op; opiods, antiholinergics, antipsychotics; peritonitis or sepsis; pancreatitis, diverticulitis; trauma; shock; hypokalaemia; hypocalcaemia; hypomagnesia
767
Type of pain in biliary colic?
- RUQ radiating to right shoulder and interscapular region - may be following fatty meal - may persist for hrs - female, forty, fat, fertile - obstructive jaundice: pale stools, dark urine
768
Type of pain in acute cholecystitis?
- continous RUQ pain - Hx gallstone symptoms - fever, raised inflam markers and WCC - Murphy's sign positive
769
Type of pain in diverticulitis?
- colicky pain in LLQ - fever, raised inflam markers and WCC
770
Type of pain in AAA?
- severe central abdo pain - radiating to back - sub-acute (persistent severe abdo pain with developing shock) or catastrophic (sudden collapse) - ?CVD history
771
Characterisitc feature of intestinal obstruction?
- Hx of malignancy/previous op - vomiting - not opened bowels recently - tinkling bowel sounds
772
Tinkling bowel sounds?
Bowel obstruction
773
Aortic dissection pain vs AAA pain?
AD= severe, sharp, tearing, acute in chest or back AAA= deep, severe central abdo pain (rupture), radiates to back
774
Epigastric pain relieved by eating?
duodenal ulcer
775
Epigastric pain worsened by eating?
gastric ulcer
776
Constipation?
Defecation that is unsatisfactory due to infrequent stools, difficulty passing stools or sensation of incomplete empyting. Functional disorder that may develop secondary to another condition.
777
Rome IV diagnostic criteria for constipation?
spontaneous bowel movements occuring <3x per w
778
Chronic constipation?
present at least 3m
779
Faecal loading/impaction?
retention of faeces to the extent that spontaneous evacuation is unlikely
780
Functional (primary or idiopathic) constipation?
chronic constipation without known cause
781
Secondary (organic) constipation?
constipation caused by drug or ULC
782
Population constipation is more common in?
women, elderly, during pregnancy
783
Assessment of constipation?
- red flags - normal pattern: freq, consistency - ?symptoms of impaction and/or incontinence - associated rectal, abdo, urinary symp - severity and impact on QOL - RFs/secondary casues - self-help or drugs tried - abdo and rectal exam
784
Mx of chronic constipation?
- TUC - advice: fibre, fluids, activity level - Mx of any faecal loading and/or impaction first - laxatives step approach - gradually titrate laxative dose up or down to produce soft formed stools without straining at least 3x week - if persist then prucalopride - review
785
Oral laxatives for constipation?
1st= bulk-forming eg. ispaghula (must have adequate fluids) 2nd= + or switch to osmotic/stool-softening laxative eg. macrogol or 2nd: lactulose 3rd= + stimulant laxative eg. senna (Senokot)
786
In constipation, what if symptoms are ongoing or refractory to laxatives?
- bloods to exclude ULC - ?defecatory disorder eg. pelvic floor dyssynergia contributing
787
When to refer to gastro or colorectal surgeon in constipation?
- suspect serious ULC eg, colorectal ca - cannot be managed in secondary care - persist
788
When to suspect faecal loading or impaction?
- hard lumpy stools which are large and infrequent (eg. every 7-10 days) OR small and relatively frequent (2-3d) - have to use manual methods to extract faeces - overflow faecal incontinence or loose stool
789
When to consider constipation in the elderly?
- confusion, delirium or functional decline - N or loss of appetite - overflow diarrhoea - urinary retention
790
Mx of faecal loading and/or impaction?
Hard stools= high dose oral macrogol Soft stools or ongoing hard stools= oral stimulant laxative If inadequate or too slow then: - suppository= bisacodyl for soft or glycerol for hard - mini enema= docusate (softener and weak stimulant) - still inadequate= sodium phosphate enema
791
Loin pain typically is in what region?
between lower ribs and buttocks either side of the spine
792
Where can loin pain originate?
- kidneys - adrenal glands - parts of colon - MSK - referred from other areas eg. abdo or pelvic organs
793
What transmit pain signals to the CNS in the renal capsule, ureter and muscles?
renal capsule, ureter and muscles richly supplied with nociceptors that transmit pain signals
794
Differential diagnosis of loin pain?
- renal colic - pyelonephritis - MSK pain (strains or sprains affecting muscles, ligaments or joints) - radiculopathy (compression/inflam of spinal nerve roots causing referred loin pain) - ruptured AAA (abdo pain radiating to back can be interpreted as loin pain)
795
Mx of loin pain?
- identify possible life-threatening conditions eg. ruptured AAA - abdo, renal and neuro exam - bloods (FBC, renal function), urinalysis, USS or CT - pain Mx while Ix is crucial
796
Differential diagnosis for abdo swelling?
- pregnancy (young female, amenorrhoea) - intestinal obstruction - ascites - urinary retention - ovarian ca
797
Characteristic features of ascites?
History of alcohol XS, cardiac failure
798
Characteristic features of urinary retention?
- Hx of prostate problems - dullness to percussion around suprapubic area
799
Characteristic features of ovarian ca?
- older female - pelvic pain - urinary symptoms eg. urgency - raised CA-125 - early satiety, bloating
800
Dyspepsia?
describes a complex of upper GI symptoms that are typically present for 4+w: upper abdo pain/discomfort, heartburn, acid reflux, nausea and/or vomiting
801
Gastro-oesophageal reflux disease (GORD)?
chronic condition where there is reflux of gastric contents back into oesophagus, causing heartburn and acid regurg
802
'Proven GORD'?
endoscopically-determined reflux disease
803
'Proven GORD' may be due to what?
- oesophagitis= oesophageal inflam and mucosal erosions seen on endoscopy - endoscopy-negative reflux disease (non-erosive reflux disease)= symptoms of GORD but endoscopy normal
804
RFs for GORD?
- obesity - trigger foods eg. spicy - smoking - alcohol - coffee - stress - pregnancy - drugs that decrease lower oesophageal sphincter pressure
805
What drugs may cause GORD?
those that decrease LOS pressure eg. CCB, anticholinergics, theophylline, benzodiazepines, nitrates, NSAIDs
806
10-15% of people with GORD will develop what?
Barrett's oesophagus; 1-10% of these will develop oesophageal adenocarcinoma over next 10-20yrs
807
Initial Mx for GORD?
- lifestyle - Review meds eg. stop NSAIDs - Antacids eg. Gaviscon but short term only - full dose PPI 4w to aid healing for proven GORD - 8w if severe oesophagitis If H.pylori +ve then eradication regimen
808
Lifestyle advice for GORD?
sleep with head of bed raised (no additional pillows as may make worse but add wood or bricks under bed head), stop any drugs that make symptoms worse if appropriate, smaller meals, evening meal 3-4hrs before bed
809
Mx for GORD if refractory or recurrent symptoms?
- alternative diagnosis: cardiac or hepatobiliary disease - adherence? - further 4w PPI or double dose - severe= further w - or + histamine (H2)-receptor antagonist at bedtime for 2w if confirmed oesophagitis - or full-dose PPI long-term maintenance if symptoms of severe oesophagitis are controlled
810
People on long-term Mx for GORD should be what?
- annual review - encourages to step down or stop if appropriate
811
When to refer to gastro or GI surgeon for GORD?
- refractory to Mx, persistent or unexplained - controlled on acid suppression therapy but doesn't want long-term Mx - RFs for Barrett's oesophagus
812
Specialist Ix for GORD?
- oesophageal manometry if motility disorder suspected eg. achalasia - ambulatory 24hr oesophageal pH monitoring - barium swallow to exclude hiatus hernia or motility disorder
813
Specialist Mx for GORD?
GOLD= laparoscopic fundoplication
814
Example of PPI for GORD?
lansoprazole 30mg OD (standard/full dose); if double dose then twice d omeprazole 20mg OD (40mg if severe); if double dose then 40mg OD (or 40mg twice d if severe)
815
H2-receptor antagonist for GORD?
ranitidine 150mg twice day or 300mg at night famotidine 20-40mg twice day
816
Ix for dyspepsia (maybe thinking possible GORD)?
- Test for H.pylori (carbon-13 urea breath test of stool antigen test) - Trial PPI 4w - Refer for upper GI endoscopy if recurrent or refractory symptoms despite Mx or second-line H.pylori eradication unsuccessful - if +ve for H.pylori= first line H.pylori eradication regimen
817
What once treated for H.pylori?
no need to test for eradication if symptoms have resolved but if repeat testing is needed then carbon-13 urea breath test used
818
Who needs a 2ww endoscopy for suspected oesophageal or stomach ca?
- All pts with dysphagia - Upper abdo mass - >=55yrs with weight loss AND upper abdo pain, reflux or dyspepsia
819
What pts need non-urgent upper GI endoscopy?
- haematemesis - >=55yrs with: treat-resistant dyspepsia or raised platelet count (with N&V, reflux, upper abdo pain) or N/V with reflux/dyspepsia/upper abdo pain
820
Diarrhoea?
Passage of 3+ loose or liquid stools per day (or more frequently than normal)
821
Acute diarrhoea?
lasts <14d
822
Persistent diarrhoea?
>14d
823
Chronic diarrhoea?
>4w
824
Causes of acute vs chronic diarrhoea?
Acute= bacterial or viral infection; meds; anxiety; food allergy; acute appendicitis Chronic= IBS; diet; IBD; coeliac; bowel ca
825
Assessment for diarrhoea should include what?
- onset, duration, frequency, severity - red flags - underlying cuase - Cx eg. dehydration
826
Acute diarrhoea Ix?
Stool sample for M&C if: - systemically unwell - blood or pus - immunocompromised - recently had Abx, PPI or hospital admission - foreign travel (also test for ova, cysts and parasites) - Persistent - need to exclude infection
827
Ix for chronic diarrhoea?
Bloods: FBC, U&E, LFTS, Ca, B12, folate, ferritin, TFTs, ESR&CRP, coeliac serology
828
Onset of diarrhoea within 6hrs of contaminated food suggets what casue?
pre-formed toxin of Bacillus cereus or staph aureus
829
Red flags for diarrhoea?
- blood, mucus - recent hospital admission or Abx - weight loss - evidence of dehydration - nocturnal symptoms (organic cause more unlikely)
830
Signs of mild dehydration?
Lassitude. Anorexia, nausea. Light-headedness. Postural hypotension. Usually no signs.
831
Signs of moderate dehydration?
Apathy/tiredness. Dizziness. Nausea/headache. Muscle cramps. Pinched face. Dry tongue or sunken eyes. Reduced skin elasticity. Postural hypotension. Tachycardia. Oliguria.
832
Signs of severe dehydration?
Profound apathy. Weakness. Confusion, leading to coma. Shock. Tachycardia. Marked peripheral vasoconstriction. Systolic blood pressure less than 90 mmHg. Oliguria or anuria.
833
Diagnosis for dehydration?
- clinical - GOLD= plasma or serum osmolality
834
Causes of diarrhoea: signs of gastroenteritis?
abdo pain or N&V, diarrhoea
835
Causes of diarrhoea: signs of diverticulitis?
LIF pain, diarrhoea, fever
836
Causes of diarrhoea: signs of Abx therapy?
more common with broad spectrum Abx C.DIFF can be seen
837
Causes of diarrhoea: signs of constipation causing overflow?
Hx of alternating diarrhoea and constipation may be given; may lead to faecal incontinence in elderly
838
Causes of diarrhoea: signs of IBS?
common abdo pain, bloating, change in bowel habit lethargy, N, backache, bladder symptoms may be present
839
Causes of diarrhoea: signs of UC?
bloody diarrhoea, crampy abdo pain, weight loss, faecal urgency, tenesmus
840
Causes of diarrhoea: signs of crohn's?
crampy abdo pain, diarrhoea, blood less common mouth ulcers, perianal disease, malabsorption, intestinal obstruction
841
Causes of diarrhoea: signs of colorectal ca?
depend on site of lesion diarrhoea, rectal bleeding, anaemia, constitiutional symptoms (eg. weight loss, anorexia)
842
Causes of diarrhoea: signs of coeliac disease?
children= failure to thrive, diarrhoea, abdo distention adults= lethargy, anaemia, diarrhoea, weight loss other autoimmune conditions may coexist
843
Thyrotoxicosis, laxative abuse, appendicitis and radiation enteritis may be associated with what?
diarrhoea
844
Diarrhoea: public health indication?
diarrhoea in high risk people (eg. food handlers, healthcare workers, elderly residents in care homes); suspected food posioning (eg. after bbq, restaurant, eggs, chicken, shellfish) food poisoning is notifiable disease
845
If diarrhoea is severe, what may bloods show?
- AKI - hypokalaemia - hyponatraemia
846
Achalasia?
failure of oesophageal peristalsis and relaxation of lower oesophageal sphincter (LOS)
847
What is achalasia due to?
degenerative loss of ganglia from Auerbach's plexus i.e. LOS contracted, oesophagus above dilated
848
Achalasia typically presents in who?
middle-aged both men and women
849
Dysphagia of BOTH liquids and solids?
Achalasia?
850
CP of achalasia?
- dysphagia BOTH liquids and solids - variation in severity of symptoms - heartburn - regurg of food- may lead to cough, aspiration pneumonia ect - malignant change in small no. of pts
851
Ix for achalasia?
- DIAGNOSTIC (most important)= oesophageal manometry: XS LOS tone which doesn't relax on swallowing - Barium swallow: grossly expanded oesophagus, fluid level; bird beak - CXR= wide mediastinum; fluid level
852
Bird's beak appearance on barium swallow?
achalasia
853
Mx of achalasia?
- 1st line= pneumatic (balloon) dilation - recurrent/persistent= surgical Heller cardiomyotomy
854
New-onset dysphagia?
red flag regardless of age or other symptoms; require urgent endoscopy
855
Causes of dysphagia?
- oesophageal ca - oesophagitis - achalasia - pharyngeal pouch - systemic sclerosis - MG - globus hystericus
856
Extrinsic causes of dysphagia?
- mediastinal mass - cervical spondylosis
857
Oesophageal wall causes of dysphagia?
- achalasia - diffuse oesophageal spasm - hypertensive LOS
858
Intrinsic causes of dysphagia?
- tumours - strictures - oesophageal web - Schatzki rings
859
Neuro causes of dysphagia?
- CVA - Parkinson's - MS - MG - brainstem pathology
860
Best type of Ix for motility disorders causing dysphagia?
barium swallow
861
Ix for dysphasia?
- ALL= upper GI endoscopy - FBC - Ambulatory oesophageal pH and menometry studies for pts with achalasia or GORD being considered for fundoplication surgery
862
Heartburn, odynophagia (painful swallowing) but no weight loss and systemically well?
Oesophagitis
863
What may there be a history of in oesophageal candidiasis causing dysphagia?
HIV or other RFs eg. steroid inhaler use
864
What may be seen in systemic sclerosis causing dysphagia?
Other features of CREST syndrome may be present, namely Calcinosis, Raynaud's phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia Oesophageal dysmotility and LOS pressure decreased
865
Systemic sclerosis causing dysphasia vs achalasia causing dysphagia?
Achalasia= LOS pressure increased SS= LOS pressure decreased
866
In MG you get dysphagia of what?
solids and liquids
867
Globus hystericus causing dysphagia?
- Hx of anxiety - intermittent and relieved by swallowing - painless
868
What is most common cause of acute upper GI bleed?
oesophageal varices or peptic ulcer disease
869
Why is urea high in upper GI bleed?
blood is digested into protein (urea is final breakdown product of amino acids in protein)
870
CP of acute upper GI bleed?
- haematemesis: bright red or coffee ground - melena: passage of altered blood per rectum, black and tarry - raised urea (due to the 'protein meal' of the blood) - features associated with particular diagnosis eg. oesophageal varices= stigmata of chronic liver disease PUD= abdo pain
871
Oesophageal causes of acute upper GI bleed?
- varices - ca - Mallory Weiss tear - Oesophagitis
872
DIfferential diagnosis for acute upper GI bleed can be separated into what groups?
- oesophageal - gastric - duodenal
873
Causes of acute upper GI bleed: CP of oesophageal varices?
- large vol fresh blood - swallowed blood may cause melena - associated with haemodynamic compromise - may stop spontaneously but re-bleeds are common until Mx
874
Causes of acute upper GI bleed: CP of oesophagitis?
- small vol fresh blood, often streaking vomit - melena rare - often ceases spontaneously - Hx of antecedent GORD symptoms
875
Causes of acute upper GI bleed: CP of oesophageal ca?
- small vol blood unless a preterminal event with erosion of major vessels - dysphagia, weight loss - recurrent until Mx
876
Causes of acute upper GI bleed: CP of Mallory Weiss tear?
- brisk small to moderate vol of bright red blood following bout of repeated vomiting - melena rare - usually ceases spontaneously
877
Gastric causes of acute upper GI bleed?
- ulcer - ca - dieulafoy lesion - diffuse erosive gastritis
878
Causes of acute upper GI bleed: CP of gastric ulcer?
- small low-vol bleeds common so present as iron def anaemia - erosion into signif vessel may produce haemorrhage and haematemesis
879
Causes of acute upper GI bleed: CP of gastric ca?
- frank haematemesis or altered blood mixed with vomit - prodromal features of dyspepsia and weight loss - amount of bleeding variable but erosion of major vessel may produce haemorrhage
880
Causes of acute upper GI bleed: CP of Dieulafoy lesion?
- arteriovenous malformation - no prodromal features prior to haematemesis and melena - can produce considerable haemorrhage - difficult to detect endoscopically
881
Causes of acute upper GI bleed: CP of diffuse erosive gastritis?
- haematemesis and epigastric discomfort - underlying cause eg. NSAIDs - large vol haemorrhage may occur with haemodynamic compromise
882
Duodenal causes of acute upper GI bleeding?
- ulcer - aorto-enteric fistula
883
Causes of acute upper GI bleed: CP of duodenal ulcer?
- posteriorly sited and may erode gastroduodenal artery - haematemesis, melena, epigastric discomfort - occurs several hrs after eating - periampullary tumours may bleed but are rare
884
May duodenal ulcers may erode what artery?
gastroduodenal
884
Causes of acute upper GI bleed: CP of aorto-enteric fistula?
- pts with prev AAA surgery - rare - major haemorrhage - high mortality
885
Risk assessments for acute upper GI bleed?
- Glasgow-Blatchford score at 1st assessment= ?pts be Mx as outpts or not - Rockall score= after endoscopy; % risk of rebleeding and mortality; incl- age, features of shock, co-morbidities, aetiology of bleed and endoscopic stigmata of recent haemorrhage
886
What is the Glasgow-Blatchford score risk assessment?
help determine if pt with upper GI bleed can be Mx as outpatient - urea, Hb, SBP, gender, HR, melena, syncope, hepatic disease Hx, cardiac failure present - score of 0= can be Mx as outpatient so can be considered for early discharge - score >0= high risk GI bleed that is likely to require medical intervention
887
Resuscitation for acute upper GI bleed?
- ABC, wide-bore IV access x2 - platelet trans if actively bleeding platelet count <50x10*9/l - fresh frozen plasma to pts with fibrinogen <1g/l or prothrombin time (INR) or APTT >1.5 times normal - prothrombin complex concentrate to pts taking warfarin and actively bleeding
888
Mx of acute upper GI bleed?
resuscitation then endoscopy within 24hrs - no PPI before endoscopy to pts with suspected variceal upper GI bleed
889
Mx of non-variceal acute upper GI bleed?
- PPI after endoscopy - further bleeding then repeat endo, interventional radiotherapy and surgery
890
Mx of variceal acute upper GI bleed?
- terlipressin and prophy Abx at presentation (before endo) - oesophageal varices= band ligation - gastric= injections of N-butyl-2-cyanoacrylate - if not controlled= transjugular intrahepatic portosystemic shunts (TIPS)
891
Why are pts with liver cirrhosis at risk of oesophageal varices?
Pt with liver cirrhosis at risk of developing portal HTN (increased portal venous system pressure) and one of most signif Cx of this is oesophageal carices.
892
What is the risk of oesophageal varicies?
Rupture -> severe and life-threatening upper GI bleed
893
Acute Mx of variceal haemorrhage?
- ABC: resus before endo; blood transfusion may be needed - Correct clotting: may need FFP, vit K, platelet trans - Vasoactive agent (terlipressin) and prophylactic IV Abx (quinolones) before endoscopy - Endoscopy: endoscopic band ligation - Uncontrolled= Sengstaken-Blakemore tube - Still fail= TIPSS (connects hepatic vein to portal vein; Cx is exacerbation of hepatic encephalopathy)
894
What does TIPPS stand for?
Transjugular Intrahepatic Portosystemic Shunt
895
Prophylaxis of variceal haemorrhage?
- Propanolol - Endoscopic variceal band ligation: for pts with cirrhosis with medium to large oesophageal varices. - PPI also given to prevent EVL-induced ulceration - unsuccessful= TIPSS
896
Causes of jaundice in pregnancy?
- intrahepatic cholestasis of preg - acute fatty liver of preg - HELLP - Gilbert's, Dubin-Johnson syndrome may be exacerbated in pregprim
897
Jaundice?
clinical sign describing yellow pigmentation of skin, sclera and mucous membranes due to raised plasma bilirubin
898
Jaundice is the result of what?
dysfunction in bilirubin metabolism
899
How are causes of jaundice characterised?
pre-hepatic hepatic post-hepatic
900
Pre-hepatic causes of jaundice?
haemolytic anaemia, drugs, malaria, Gilbert's syndrome, Crigler-Najjar syndrome
901
Intra-hepatic causes of jaundice?
Viral hepatitis, alcohol misuse, autoimmune disorders, drugs, malignancy of biliary system, Dubin-Johnson syndrome and Rotor's syndrome
902
Post-heptaic causes of jaundice?
Gallstones, surgical strictures, extra-hepatic malignancy, pancreatitis and parasitic infections
903
Most important causes of jaundice?
malignancy, alcohol and gallstone disease
904
Assessment/Ix for pt with jaundice?
- duration of current episode; previous episodes; changes in stool and urine; itching; pain; systemic (fever, arthralgia, myalgia, rash, fatigue, weight loss, N&V); recent travel abroad; Hx of IVDU or blood transfusion; exposure to hepatotoxic drugs; occupation - exam: signs of chronic liver disease, lymphadenopathy, abdo masses, tenderness or ascites - Urine sample: bilirubin - Not acutely unwell= FBC, LFTs, U&E, clotting, hepatitis screen, alpha-1-antitrypsin (metabolic liver disease) - May need referral or additional screening tests eg. full liver screen and imaging eg. USS or CT
905
Red flags associated with jaundice?
hepatic encephalopathy (confusion); hepatic dysfunction (bruising); GI blood loss; sepsis; marked abdo pain or tenderness; V; weight loss; paracetamol overdose
906
When to admit pt for same-day assessment if present with jaundice?
- acutely unwell eg. confusion, fever - cholangitis suspected - Bilirubin >100micromol/L - Renal function abnormal or dehydrated - Clotting profile abnormal - Frail/co-morbidities - Paracetamol overdose
907
When should pts who do not need admission be referred to secondary care if they present with jaundice?
- 2ww if suspect malignancy - Bloods show cholestatic or obstructive picture - bloods show hepatitic picture - alcohol-related liver disease suspected - inherited or autoimmune liver disease suspected
908
What pts with jaundice can be managed in primary care?
if have been diagnosed with hep A or Gilbert's syndrome
909
When examining a pt with jaundice, what should you look out for?
- signs of sepsis - signs of chronic liver disease= palmar erythema, spider naevi, clubbing, leukonychia, Dupuytren's contractures, gynaecomastia with loss of body hair and testicular atrophy - signs of liver failure= altered neuromusc function eg. ataxia, nystagmus or asterixis (corarse flapping temor), drowsiness, confusion, bruising, petechiae, purpura - lymphadenopathy - masses= hepato or splenomegaly; Courvoiser's sign (palpable gallbladder) - Abdo tenderness= Murphy's sign or widespread - Visible veins eg. collateral vessels on skin of abdo espec around umbilicus (caput medusae)= chronic liver disease - ascites
910
Palmar erythema, spider naeivi, clubbing, Dupuytren;s contractures, gynaecomastia?
Chronic liber disease
911
Clubbing can be associated with liver...
cirrhosis
912
Dupuytren's contracture?
contacture of palmar fascia associated with chronic liver disease due to alcohol misuse, famillial or DM
913
Ataxia, systagmus, asterixis (coarse flapping tremor), confusion, petechiae or purpura?
Liver failure
914
Enlargement of supraclavicualar lymph nodes (Troisier's sign)?
malginancy eg. metastatic pancreatic and gastric ca
915
LFTs: isolated raised bilirubin?
Often due to Gilbert's syndrome - repeat LFT and FBC to ensure no anaemia or haemolysis
916
LFTs: cholestatic picture?
- Raised ALP - Causes= primary biliary cholangitis, primary sclerosing cholangitis, biliary obstruction, liver congestion and drug-induced liver injury. Bone disease can also cause raised ALP so repeat and add GGT to confirm liver cause
917
LFTs: hepatitic picture?
- Raised ALT and AST - ALP may be raised - Caused by hepatocellular liver injury secondary to viral hep; NAFLD; alcohol realted liver disease; autoimmune hep or drug induced
918
LFTs: what can cause ALT to rise to several thousand units per litre (U/L)?
acute viral hepatitis
919
LFTs: what can produce ALT levels >10,000 U/L?
Acute liver injury from drugs (eg. paracetamol overdose) or ischaemia
920
LFTs: what can cause AST and ALT to rise to several hundred?
acute alcoholic hepatitis
921
LFTs: what usually causes ratio of AST:ALT >1 and what causes ALT to rise more than AST?
AST:ALT >1= alcohol-induced hepatocyte damage ALT rises more than AST= infection
922
Are AST and ALT raised in obstructive jaundice?
no unless complicated by cholangitis
923
LFTs: mixed picture?
both cholestasis and hepatocyte damage eg. due to cholangitis associated with stones in common bile duct
924
LFTs: albumin?
marker of liver synthesising function. low serum albumin suggests chronic liver disease
925
What is tested in LFTs?
ALT and AST; ALP; GGT; serum bilirubin; prothrombin time (PT); international normalised ratio (INR); total protein and albumin
926
Primary sclerosing cholangitis?
biliary disease of unknown aetiology characterised by inflam and fibrosis of intra and extra-hepatic bile ducts
927
Primary sclerosing cholangitis associations?
- UC: 4% with UC have PSC and 80% with PSC have UC - Crohn's - HIV
928
Features of primary sclerosing cholangitis?
- cholestasis= jaundice, pruritis; raised bilirubin + ALP - RUQ pain - fatigue
929
Ix for primary sclerosing cholangitis?
- ERCP or MRCP diagnostic= multiple biliary strictures giving beaded appearance - p-ANCA may be +ve - liver biopsy (limited)= fibrous obliterative cholangitis described as onion skin
930
ERCP or MRCP showing multiple biliary strictures giving beaded appearance?
Primary sclerosing cholangitis
931
Cx of primary sclerosing cholangitis?
- cholangiocarcinoma (10%) - increased risk colorectal ca
932
Mx for primary sclerosing cholangitis?
manage Cx and monitor liver damage eg. ursodeoxycholic acid for pruritis cure=transplant
933
Common causes of hepatomegaly?
- cirrhosis if early (later it gets smaller); non-tender firm liver - malignany: metastatic or primary hepatoma; hard, irregular liver edge - RHF: firm smooth tender liver edge, may be pulsatile
934
Other causes of hepatomegaly?
- viral hep - glandular fever - malaria - abscess: pyogenic, amoebic - hydatid disease - haem malignancies - haemochromatosis - primary biliary cirrhosis - sarcoidosis, amyloidosis
935
Causes of hepatosplenomegaly?
- chronic liver disease with portal HTN (unless later cirrhosis) - infections: glandular fever, malaria, hepatitis - lymphoproliferative disorders - myeloproliferative disorders eg. CML - amyloidosis
936
Causes of massive splenomegaly?
- myelofibrosis - chronic myeloid leukaemia - visceral leishmaniasis (kala-azar) - malaria - Gaucher's syndrome
937
Other causes of splenomegaly?
massive causes plus... - portal HTN eg. 2 to cirrhosis - lymphoprolferative disease eg. CLL, Hodgkin;s - haemolytic anaemia - infection: hepatitis, glandular fever - infective endocarditis - sickle-cell*, thalassaemia - rheumatoid arthritis (Felty's syndrome) * majority with sickle cell will have atrophied spleen due to repeated infection
938
Examples of anorectal disorders?
haemorrhoids anal fissure proctitis ano rectal abscess anal fistula rectal prolapse pruritus ani anal neoplasm solitary rectal ulcer
939
Anorectal disorders: summary of haemorrhoids?
Location= 3,7,11 o'clock Internal or external Mx= conservative, rubber band ligation, haemorrhoidectomy
940
Anorectal disorders: summary of anal fissure?
Painful rectal bleeding Location= midline (posterior 90%) 6 and 12 o'clock; distal to dentate line Chronic fissure >6/52: triad= ulcer, sentinel pile, enlarged anal papillae
941
Anorectal disorders: summary of ano rectal abscess?
E.coli, staph aureus Positions= perianal, ischiorectal, pelvirectal, intersphincteric
941
Anorectal disorders: causes of proctitis?
Crohn's; UC; c.diff
942
Anorectal disorders: summary of anal fistula?
usually due to previous ano-rectal abscess Intersphincteric, transsphincteric, suprasphincteric and exterasphincteric. Goodsalls rule determines location.
943
Anorectal disorders: summary of rectal prolapse?
associated with childbirth and rectal intusscecption. internal or external
944
Anorectal disorders: summary of pruritus ani?
very common children= often related to worms adults= idiopathic or related to other causes eg. haemorrhoids
945
Anorectal disorders: summary of anal neoplasm?
Most common= SCC unlike adenocarcinoma in rectum
946
Anorectal disorders: summary of solitary rectal ulcer?
associated with chronic straining and constipation histology= mucosal thickening, lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)
947
Threadworm (Enterobius vermicularis) or pinworm?
parasitic worm that infects the human gut
948
Threadworm (Enterobius vermicularis) transmission?
faecal-oral route when threadworm eggs are ingested can be ingested by hand-to-mouth transfer (after scratching) from the faeces/perianal area of infected person or by handling contaminated surfaces eg. toys, bedding or clothing
949
Most common parasitic worm infestation in UK?
Threadworm
950
Who does threadworm (Enterobius vermicularis) most commonly affect?
- <18yrs - household contacts of infected children - people living in institutions
951
Threadworm (Enterobius vermicularis) CP?
- intense perianal itching - worse at night - may be asymptomatic - small white thread-like worms (slowly moving) seen on perianal skin or in stool - females= can invl genital area so get pruritus vulvae - nocturnal itching= disturbed sleep and irritabolity
952
Ix for threadworm (Enterobius vermicularis)?
- clinical - uncertain= adhesive tape test for eggs (transparent tape applied to perianal area in morning then examined under microscopy) stool sample not generally recommended
953
Differential diagnosis for perineal and vulval itch?
- dermatitis - candidal infection - pubic lice - haemorrhoids - threadworms (rarely confused with other worm infestation because of specific appearance)
954
Mx for threadworm (Enterobius vermicularis)?
if seen or eggs detected ALL HOUSEHOLD members too. - Anthelmintic (mebendazole) single dose + hygiene measures - <6m old or pregnant= hygiene measures for 6w
955
Mx for re-infestation of threadworm (Enterobius vermicularis)?
usually due to re-infection. - consider other causes - if certain then re-treat pt and household contacts - reinforce strict hygiene measures
956
Differential diagnosis for pruritus?
- liver disease - iron def anaemia - polycythaemia - CKD - lymphoma - hyper/hypothyroidism - diabetes - pregnancy - 'senile' pruritus - urticaria - skin disorders: eczema, scabies, psoriasis, pityriasis rosea
957
Causes of pruritus: summary of liver disease?
- Hx alcohol XS - Chronic liver disease= spider naevi, bruising, palmar erythema, gynaecomastia - evidence of decompensation= ascites, jaundice, encephalopathy
958
Causes of pruritus: summary of iron def anaemia?
- pallor - Koilonychia, atrophic glossitis, post-cricoid webs, angular stomatitis
959
Causes of pruritus: summary of polycythaemia?
- pruritus particularly after warm bath - 'ruddy complexion' - gout - PUD
960
Causes of pruritus: summary of CKD?
- lethargy and pallor - oedema and weight gain - HTN
961
Causes of pruritus: summary of lymphoma?
- pruritus - night sweats - lymphadenopathy - splenomegaly, hepatomegaly - fatigue
962
Bright red rectal bleeding?
usually rectal anal canal origin
963
Dark red rectal bleeding?
usually proximally sited bleeding source
964
Cause of malaena?
blood that has entered GI tract from gastro-duodenal source due to the effects of the digestive enzymes on the blood itself
965
Common causes of rectal bleeding?
fissure in ano haemorrhoids crohn's UC rectal ca
966
Type of bleeding in fissure in ano?
bright red rectal bleeding
967
Type of bleeding in haemorrhoids?
bright red rectal bleeding
968
Type of bleeding in crohn's?
Bright red or mixed blood
969
Type of bleeding in UC?
Bright red bleeding often mixed with stool
970
Type of bleeding in rectal cancer?
Bright red blood mixed volumes
971
Main features in history in fissure in ano?
painful bleeding that occurs post defecation in small volumes usually antecedent features of constipation
972
Main features in history in haemorrhoids?
post-defecation bleeding noted both on toilet paper and drips into pan may be alteration of bowel habit and Hx of straining no blood mixed with stool, no local pain
973
Main features in history in crohn's in terms of rectal bleeding?
bleeding (but more common in UC) that is accompanied by other symptoms: altered bowel habit, malaise, Hx of fissures (espec anterior) and abscesses
974
Main features in history in UC?
Diarrhoea, bleeding, weight loss, nocturnal incontinence, passage of mucous PR
975
Main features in history in rectal ca?
Alteration of bowel habit; tenesmus may be present; symptoms of met disease
976
Main features on exam in fissure in ano?
muco-epithelial defect usually in midline posteriorly (anterior fissures more likely due to underlying disease)
977
Main features on exam in haemorrhoids?
normal colon and rectum protoscopy may show internal haemorrhoids internal haemorrhoids usually impalpable
978
Main features on exam in Crohn's?
Perineal inspection may show fissure or fistulae. Proctoscopy may demonstrate indurated mucosa and possibly strictures. Skin lesions may be noted at colonoscopy.
979
Main features on exam in UC?
Proctitis is most marked finding. Perianal disease usually absent. Colonoscopy will show continuous mucosal lesion.
980
Main features on exam in rectal ca?
Usually obvious mucosal abnormality. Lesion may be fixed or mobile depending upon disease extent. Surrounding mucosa often normal, although polyps may be present.
981
Ix for pts presenting with rectal bleeding?
ALL pts= digital rectal exam and procto-sigmoidoscopy. - ?haemorrhoids= young pt with no concerning features then Hx and sigmoidoscopy demonstrating haemorrhoids sufficient. If clear views not obtained then need bowel prep with enema and flexible sigmoidscopy. - Altered bowel habit= colonoscopy - XS pain ?fissure= may need exam under local anaesthesia
982
Ix for staging malignancy of rectum?
Staging= MRI of rectum and CT chest abdo and pelvis.
983
What Ix should pts with fissure in ano who are being considered for surgical sphincterotomy and females who have obstetric history have?
Ano rectal mamometry testing + endo anal USS not mandatory as not universally available but if not done then there is absence of info may be continence issues after sphincterotomy
984
Mx for rectal ca?
anterior resection or abdomino-perineal excision of colon and rectum total mesorectal excision now standard. Most resections below peritoneal reflection will require defunctioning ileostomy. Most pts will need pre-op radiotherapy
985
Small bowel obstruction?
Passage of food, fluids and gas through small intestines becomes blocked.
986
Most common cause of small bowel obstruction?
Adhesions (eg. follow prev surgery) then hernias.
987
Features of small bowel obstruction?
- diffuse central abdo pain - Bilious vomiting and nausea - 'constipation' with complete obstruction and lack of flatulence - abdo distension, particularly with lower levels of obstruction - tinkling bowel sounds (common in early obstruction)
988
Ix for small bowel obstruction?
- 1st line= abdo x-ray - GOLD= CT as more sensitive and definitive
989
What does abdo x-ray show in small bowel obstruction?
- distended small bowel loops with fluid levels - dilated if small bowel is >3cm diameter
990
Mx for small bowel obstruction?
- inital= NBM, IV fluids, nasogastric tube with free drainage - Some pts will settle with conservative Mx but otherwise require surgery
991
One of the key indications for performing abdo x-ray?
looking for bowel obstruction
992
Abdo x-ray in small bowel obstruction vs large?
Small: - max normal diameter= 35mm - Valvulae conniventes ectend all the way across Large: - max normal diameter= 55mm - Haeustra extend about a third of the way across
993
Large bowel obstruction?
Passage of food, fluids and gas through large intestines becomes blocked.
994
Causes of large bowel obstruction?
- Tumour (60%) - Volvulus - Diverticular disease
995
Initial presenting complaint of colonic malignancy in 30% cases?
Large bowel obstruction. Espec in more distal and rectal tumours as these tend to obstruct earlier due to the smaller lumen diameter.
996
CP of large bowel obstruction?
- absence of passing flatus or stool - abdo pain - abdo distension - N&V LATE symptoms that may suggest more proximal lesion - if perforation= peritonism - symptoms of underlying cause eg. colorectal ca so weight loss ect.
997
Ix for large bowel obstruction?
1st= abdo x-ray GOLD= CT (sensitive, specific and can identify aetiology)
998
Abdo x-ray finding for large bowel obstruction?
Normal diameter limits: - Caecum= 10-12cm - Ascending colon= 8cm - Recto-sigmoid=6.5cm So any diameter GREATER than this is diagnostic for obstruction + presence of free intra-peritoneal gas indicates colonic perforation.
999
What may presence of free-intra peritoneal gas on abdo x-ray for large bowel obstruction indicate?
colonic perforation
1000
Mx for large bowel obstruction?
urgency depends on whether perforation suspected - Initial= NBM, IV fluids, nasogastric tube with free drainage - If cause of obstruction doesn't require surgery= conservative Mx trialed up to 72hrs, if fail then further Mx (75% will require surgery) - IV Abx if surgery planned or perforation suspected - Surgery= emergency if overt peritonitis or evidence of bowel perforation. Irrigation of abdo cavity, resection of perforated segment and ischaemic bowel, and address ULC of obstruction itself
1001
Jaundice is due to hyperbilirubinaemia, occuring at bilirubin levels roughly greater than what?
50umol/L
1002
Where does bilirubin come from?
normal breakdown product from the catabolism of haem and so formed from destruction of RBCs
1003
Normal pathophysiology of bilirubin in the liver?
Bilirubin undergoes conjugation within the liver making it water-soluble -> excreted via bile into GI tract -> majority is egested in the faeces as urobilinogen and stercobilin (metabolic breakdown product of urobilinogen) -> around 10% of urobilinogen is reabsorbed into bloodstream and excreted through the kidneys jaundice occurs when this pathway is disrupted
1004
Pathophysiology of pre-hepatic jaundice?
XS RBC breakdown -> overwhelms liver's ability to conjugate bilirubin -> causes unconjugated hyperbilirubinaemia. Any bilirubin that manages to become conjugated will be excreted normally but it is the UNCONJUGATED BILIRUBIN that remains in the blood that causes the jaundice.
1005
Unconjugated vs conjugated bilirubin?
Unconjugated= form of bilirubin produced when RBCs breakdown. Not been processed by the liver and is not water-soluble so can't be removed from body easily. Binds to albumin to be transported to the liver. Conjugated= form that results after liver processess unconjugated bilirubin. Makes it water-soluble (by binding unconjug bilirubin with glucuronic acid) so it can be excreted from body through bile, into GI tract and out in stool.
1006
Pathophysiology of intrahepatic/hepatocellular jaundice?
Dysfunction of hepatic cells -> liver loses ability to conjugate bilirubin. If it becomes cirrhotic it compressess the intra-hepatic portions of the biliary tree to cause a degree of obstruction. Leads to both UNCONJUGATED and CONJUGATED bilirubin in the blood- 'mixed-picture'.
1007
Pathophysiology of post-hepatic jaundice?
Obstruction of biliary drainage. The bilirubin that is not excreted has still been conjugated by the liver so you get CONJUGATED hyperbilirubinaemia.
1008
What type of bilirubin can be excreted in urine?
conjugated as it is water soluble unconjugated cannot
1009
Why may you get dark urine in jaundice?
Conjugated or mixed hyperbilirubinaemias (as only conjugated bilirubin can be excreted in urine). In unconjugated hyperbilirubinaemia the urine is normal (unsoluble so can't be excreted in urine).
1010
Why may you get pale stools in jaundice?
If obstructive picture and there will be reduced levels of stercobilin entering GI tract which normally colours the stool.
1011
LFTs: bilirubin?
quantify degree of any suspected jaundice
1012
LFTs: albumin?
marker of liver synthesising function
1013
LFTs: AST and ALT?
markers of hepatocellular injury
1014
LFTs: alkaline phosphatase (ALP)?
raised in biliary obstruction (as well as bone disease, during pregnancy, and certain malignancies)
1015
LFTs: Gamma-GT (GGT)?
more specific for biliary obstruction than ALP; may be raised in alcohol use (not routinely performed)
1016
LFTs: AST:ALT ratio >2?
likely alcoholic liver disease
1017
LFTs: AST:ALT around 1?
likely viral hepatitis
1018
Liver screen includes what?
viral serology and non-infective markers. performed when there is no initial cause for liver dysfunction, tailored to acute or chronic liver failure
1019
Liver screen for acute liver injury?
Viral serology= - hep A, B, C, E - CMV and EBV Non-infective markers= - paracetamol level - caeruloplasmin - antinuclear antibody and IgG subtypes
1020
Liver screen for chronic liver injury?
Viral serology= - hep B, C Non-infective markers= - ceruloplasmin - ferritin and transferrin saturation - Tissue Transglutaminase antibody - Alpha-1 antitrypsin - Autoantibodies: AMA, ANA, Anti-SMA
1021
Autoantibodies in liver screen eg. for chronic liver injury?
- anti-microchondrial antibody (AMA) - anti-smooth muscle antibody (Anti-SMA) - anti-nuclear antibody (ANA) used to identify autoimmune liver conditions eg. PCS
1022
Cx of liver disease (need to monitor for)?
- Coagulopathy= vit K or fresh frozen plasma (FFP) if needed if evidence of bleeding or rapid coagulopathy. Mx hypoglycaemia orally if possible or 5% dextrose - Confusion from decompensating chronic liver disease (encephalopathy)= laxatives (lactulose or senna) +/- neomycin or rifaximin to reduce no. of ammonia-producing bacteria in bowel (no. of functional liver cells reduced, some toxins not removed eg. ammonia and can damage nerve cells and astrocytes)
1023
What may low levels of Ceruloplasmin mean?
Wilson's (copper overload)
1024
Acute liver failure?
Rapid onset hepatocellular dysfunction leading to variety of systemic Cx
1025
Causes of acute liver failure?
- paracetamol overdose - alcohol - viral hep (usually A or B) - acute fatty liver of pregnancy
1026
Features of acute liver failure?
- jaundice - coagulopathy: raised prothrombin time - hypoalbuminaemia - hepatic encephalopathy - renal failure common (hepatorenal syndrome)
1027
How is liver function best assessed?
Prothrombin time and albumin level. LFTs not always reflect function of liver accurately. eg. in cirrhosis the liver's ability to synthesise proteins is compromised so get low albumin.
1028
Men and women should drink no more than how many units?
14 per week spread evenly over 3d+
1029
1 unit of alcohol is equal to what?
10mL pure ethanol
1030
Examples of 1 unit of alcohol?
- 25ml single measure of spirit (ABV 40%) - a third of a pint of beer (ABV 5-6%) - half a 175ml 'standard' glass of red wine (ABV 12%)
1031
Calculate no. of units?
(ml x ABV)/1000
1032
Alcoholic ketoacidosis?
Non-diabetic euglycaemic form of ketacidosis occuring in people who regularly drink large amounts of alcohol.
1033
Pathophysiology of alcoholic ketoacidosis?
alcoholics will not eat regularly and may vomit food if they do eat -> episodes of starvation -> malnourished -> after alcohol binge the body starts to break down fat producing ketones -> ketoacidosis
1034
What does alcoholic ketoacidosis typically present with?
- metabolic acidosis - elevated anion gap - elevated serum ketone levels - normal or low glucose conc
1035
Mx for alcoholic ketoacidosis?
IV saline + thiamine (to avoid Wernicke encephalopathy or Korsakoff psychosis)
1036
Angiodysplasia?
Vascular deformity of GI tract which predisposes to bleeding and iron def anaemia
1037
Angiodysplasia is generally seen in who?
elderly ?association with aortic stenosis
1038
Featues of angiodysplasia?
- anaemia - GI bleeding= upper (melena) or lower (brisk, fresh red PR bleeding)
1039
Diagnosis of angiodysplasia?
- colonoscopy - mesenteric angiography if acutely bleeding
1040
Mx of angiodysplasia?
- endoscopic cautery or argon plasma coagulation - antifibrinolytics e.g. Tranexamic acid - oestrogens may also be used
1041
Leukotrienes (in arachidonic acid metabolism)?
- LTB4: B4 (before) leukocytes comes LTB$ - the rest A, C, D & E constrict the lungs
1042
Endoperoxides (in arachidonic acid metabolism)?
- THROMBOxane think THOMBOSIS= platelet aggregation and vasoconstriction - prostacyclin is the opposite + decreased uterine tone - Prostaglandin= increased pain, temp, uterine tone and gastric mucus. Decreased gastric acid. Varying effects on vascular smooth muscle and airways.
1043
Arachindonic acid metabolism?
Phospholipid ---(phospholipase A2)-----> Arachidonic acid then either... ---(COX1, COX2)--> endoperoxides or --(Lipoxygenase)---> HPETEs and HPETEs to either---> LB4 or ---> Leukotrienes (LA4, LC4, LD4, LE4)
1044
Autoimmine hepatitis?
Unknown aietiology most commonly seen in young females.
1045
Autoimmune hepatitis associations?
autoimmune disorders; hypergammaglobulinaemia; HLA B8, DR3
1046
3 types of autoimmune hepatitis that are characterised depending on what?
the type of circulating antibodies present
1047
Type I autoimmune hepatitis?
- ANA and/or ASMA - both adults and children
1048
Type II autoimmune hepatitis?
- anti-liver/kidney microsomal type 1 antibodies (LKM1) - children only
1049
Type III autoimmune hepatitis?
- soluble liver-kidney antigen - middle-aged adults
1050
Features of autoimmune hepatitis?
- signs of chronic liver disease - acute hepatitis (25%)= fever, jaundice ect - amenorrhoea (common) - ANA/ASMA/LKM1 antibodies, raised IgG levels - liver biopsy= inflam extending beyond limiting plate 'piecemeal necrosis', bridging necrosis
1051
Mx of autoimmune hepatitis?
- steroids; other immunosupressants eg. azathioprine - liver transplant
1052
Barrett's oesophagus?
metaplasia of lower oesophageal mucosa= stratified squamous epithelium replaced by columnar
1053
Risk of what with Barrett's?
oesophageal adenocarcinoma (50-100fold)
1054
Is there screening for Barrett's?
no- typically identified who pt has endoscopy for upper GI symptoms eg. dyspepsia
1055
How is Barrett's subdivided?
short (<3cm) and long (>3cm)
1056
Histological features of Barrett's?
columnar epithelium may resemble that of the cardiac region of the stomach of small bowel (eg. with goblet cells, brush border)
1057
RFs for Barrett's?
- GORD (strongest) - male - smoking - central obesity alcohol isn't even though it is for GORD and oeso ca
1058
CP of Barrett's?
asymptomatic but with have coexistent GORD symptoms
1059
Mx of Barrett's?
- high dose PPI - if metaplasia (but not dysplasia)= endoscopic surveillance with biopsies every 3-5yrs - if dysplasia of any grade is identified= endoscopic intervention eg. radiofrequency ablation
1060
Metaplasia vs dysplasia?
M= transformation of one cell type into another type D= transformation of one cell type to abnormal version of itself
1061
Bile acid malabsorption is a cause of what?
Chronic diarrhoea
1062
Bile acid malabsorption can be what?
primary= XS production of bile acid or secondary= underlying GI disorder causing reduced bile acid absorption
1063
What can bile-acid malabsorption lead to?
- chronic diarrhoea - steatorrhoea - vit A, D, E, K malabsorption
1064
Secondary causes of bile acid malabsorption?
- pts with ileal disease eg. Crohn's - cholecystectomy - coeliac - small intestinal bacterial overgrowth
1065
Ix for bile-acid malabsorption?
SeHCAT (nuclear medicine test using a gamma-emitting selenium molecule in selenium homocholic acid taurine or tauroselcholic acid (SeHCAT)) - scans are done 7 days apart to assess the retention/loss of radiolabelled 75SeHCAT
1066
Mx of bile-acid malabsorption?
Cholestyramine (bile acid sequestrant)
1067
Budd-chiari syndrome?
or hepatic vein thrombosis usually seen in context of underlying haem disease or another precoagulant condition
1068
Causes of Budd-Chiari syndrome (hepatic vein thrombosis)?
- polycythaemia rubra vera - thrombophilia: activated protein C resistance, antithrombin III def, protein C & S def - preg - COCP (20% cases)
1069
Triad of Budd-Chiari syndrome (hepatic vein thrombosis)?
- abdo pain: acute, severe - ascites= abdo distention - tender hepatomegaly
1070
Ix for Budd-Chiari syndrome (hepatic vein thrombosis)?
USS with Doppler flow studies
1071
Mx for Budd-Chiari syndrome (hepatic vein thrombosis)?
- anticoagulants mainly - thrombolysis and stenting
1072
Carcinoid tumours (carcinoid syndrome)?
occurs when mets are present in liver and release serotonin into systemic circulation; may also occur with lung carcinoid as mediators are not 'cleared' by the liver
1073
Carcinoid tumours (carcinoid syndrome) CP?
- flushing (early) - diarrhoea - bronchospasm - hypotension - right heart valvular stenosis (left heart in bronchial carcinoid) - ACTH and GHRH may be secreted so get eg. Cushing's - pellagra (rare)= dietary tryptophan is diverted to serotonin by tumour
1074
Ix for Carcinoid tumours (carcinoid syndrome)?
- urinary 5-HIAA - plasma chromogranin A y
1075
Mx for Carcinoid tumours (carcinoid syndrome)?
- somatostatin analogues eg. octreotide - diarrhoea= cyproheptadine
1076
Drug-induced liver disease can be divided into what?
- hepatocellular - cholestatic - mixed
1077
Drugs that can cause a hepatocellular picture in drug-induced liver disease?
- PARACETAMOL - sodium valproate, phenytoin - MAOIs - halothane - anti-tuberculosis: isoniazid, rifampicin, pyrazinamide - statins - alcohol - amiodarone - methyldopa - nitrofurantoin
1078
Drugs that can cause cholestasis (+/- hepatitis) in drug-induced liver disease?
- COCP - Abx= co-amoxiclav, fluclox, erythromycin - anabolic steroids, testosterones - phenothiazines: chlorpromazine, prochlorperazine - sulphonylureas - fibrates - rare reported causes: nifedipine
1079
Drugs that may cause liver cirrhosis in drug-induced liver disease?
- methotrexate - methyldopa - amiodarone
1080
Ferritin?
intracellular protein that binds iron and stores it to be released in controlled fashion at sites where iron is required
1081
What level is classed as increased ferritin?
>300ug/L in men/postmenopausal women and >200ug/L in premenopausal women
1082
Why may falsely elevated results of ferritin be encountered clinically?
Ferritin is an acute phase protein and may be synthesised in increased quantities in situations where there is inflammation; so take elevated ferritin in context of the clinical picture and blood results.
1083
Causes of increased ferritin?
- Without iron overload (90% pts)= inflammation (due to being an acute phase reactant); alcohol XS; liver disease; CKD; malignancy. - With iron overload (10%)= primary iron overload (hereditary haemochromatosis) and secondary iron overload (eg. following repeated transfusions)
1084
Best way to test to see whether iron overload is present? (is ferritin actually high or is it just high due to inflam, alcohol ect)
Transferrin saturation= <45% in females and <50% in males EXCLUDE iron overload
1085
What may cause reduced ferritin levels?
iron def anaemia (iron and ferritin are bound, so the total ferritin levels may be decreased)
1086
What can be useful to determine whether an apparently low Hb and microcytosis is truly caused by an iron def state?
serum ferritin levels
1087
Gilbert's syndrome?
Autosomal recessive condition of defective bilirubin conjugation due to a deficiency of UDP glucuronosyltransferase. 1-2% of population.
1088
Gilbert's is due to def of what?
UDP glucuronosyltransferase
1089
Features of Gilbert's syndrome?
- unconjugated hyperbilirubinaemia (so not in urine) - jaundice= may only be seen during intercurrent illness, exercise or fasting
1090
Ix and Mx for Gilbert's syndrome?
Ix= rise in bilirubin following prolonged fasting or IV nicotinic acid Mx= no treatment needed (benign condition, only mild rise in bilirubin)
1091
Unconjugated hyperbilirubinaemia and jaundice only when pt is ill, exercise or fasting?
Gilbert's
1092
Is Gilbert's a serious condition?
No, common and mild. Benign (harmless)- doesn't lead to liver damage or serious health problems. Just a condition that affects liver's ability to process bilirubin.
1093
Hepatic encephalopathy?
May be seen in liver disease. XS absorption of ammonia and glutamine from the bacterial breakdown of proteins in the blood/
1094
What may cause hepatic encephalopathy?
- acute liver failure (most common) - chronic eg. liver cirrhosis may get mild cognitive impairment- 'minimal' HE - TIPSS may precipitate encephalopathy
1095
Features of hepatic encephalopathy?
- confusion, altered GCS - asterixus (liver flap), arrhythmic negative myoclonus with a freq of 3-5Hz - constructional apraxia: inability to draw a 5 pointed star - triphasic slow waves on EEG - raised ammonia level (not commonly measured anymore)
1096
Grading of hepatic encephalopathy?
Grade I: Irritability Grade II: Confusion, inappropriate behaviour Grade III: Incoherent, restless Grade IV: Coma
1097
Precipitating factors of hepatic encephalopathy?
- infection e.g. spontaneous bacterial peritonitis - GI bleed - TIPSS - constipation - drugs: sedatives, diuretics - hypokalaemia - renal failure - increased dietary protein (uncommon)
1098
Mx of Hepatic encephalopathy?
TUC 1st= lactulose first line, with + rifaximin for secondary prophylaxis other= embolisation of portosystemic shunts and liver transplant
1099
Why do lactulose and Abx eg. rifaximin work for hepatic encephalopathy?
L= promotes excretion of ammonia and increases metabolism of ammonia by gut bacteria Rif= modulate the gut flora resulting in decreased ammonia production
1100
Examples of hepatobiliary conditions?
- viral hepatitis - congestive hepatomegaly - biliary colic - acute cholecystitis - ascending cholangitis - gallstone ileus - cholangiocarcinoma - acute pancreatitis - pancreatic ca - amoebic liver abscess
1101
Key features of viral hepatitis?
- N&V - anorexia - myalgia - lethargy - RUQ pain - IVDU or foreign travel
1102
Key features of congestive hepatomegaly?
liver only causes pain if stretched; common way this can occur is as a consequence of congestive HF; cirrhosis may occur in severe disease/
1103
Key features of acute cholecystitis?
- pain similar to biliary colic but more severe and persistent - pain may radiate to right shoulder or back - may be pyrexial and Murphy's sign +ve
1104
Key features of ascending cholangitis?
- infection of bile ducts commonly secondary to gallstones - triad= fever (rigors), RUQ pain, jaundice
1105
Key features of gallstone ileus?
- small bowel obstruction secondary to impacted gallstone - may develop if a fistula forms between a gangrenous gallbladder and duodenum - abdo pain, distention, vomiting
1106
Key features of cholangiocarcinoma?
- persistent biliary colic, anorexia, jaundice, weight loss - Courvoisier sign (palpable mass in RUQ) - Sister Mary Joseph Nodes (periumbilical lymphadenopathy) - Virchow mode (left supraclavicular adenopathy
1107
Key features of pancreatic ca?
- PAINLESS JAUNDICE - pain can be common presentation - anorexia, weight loss
1108
Key features of amoebic liver abscess?
- malaise, anorexia, weight loss - RUQ pain mild - jaundice uncommon
1109
Hepatorenal syndrome?
Form of impaired kidney function that occurs due to advanced liver disease.
1110
Pathophysiology of hepatorenal syndrome?
Vasoactive mediators cause splanchnic vasodilation -> reduces systemic vascular resistance -> 'underfilling' of the kidneys -> this is sensed by juxtaglomerular apparatus which then activates the renin-angiotensin-aldosterone system -> renal vasocontriction which is not enough to counterbalance the effects of splanchnic vasodilation
1111
2 types of Hepatorenal syndrome?
Type 1 HRS= rapidly progressive; very poor prognosis; doubling of serum creatinine to >221ugmol/L or a halving of the creatinine clearance to less than 20ml/min over period of less than 2w. Type 2 HRS= slowly progressive; prognosis poor but pts may live for longer
1112
Mx for hepatorenal syndrome?
- GOLD= liver transplant but often too unwell to have surgery - Vasopressin analogues eg. terlipressin= cause vasocontriction of the splanchnic circulation - volume expansion with 20% albumin - TIPSS
1113
4 inherited causes of jaundice and do they cause conjugated or unconjugated hyperbilirubinaemia?
Unconjugated= Gilbert's and Crigler-Najjar syndrome Conjugated= Dubin-Johnson syndrome and Rotor syndrome
1114
Key features of Gilbert's?
autosomal recessive mild deficiency of UDP-glucuronyl transferase benign
1115
Key features of Crigler-Najjar syndrome type 1?
autosomal recessive absolute deficiency of UDP-glucuronosyl transferase do not survive to adulthood
1116
Key features of Crigler-Najjar syndrome type 2?
slightly more common than type 1 and less severe may improve with phenobarbital
1117
Key features of Dubin-Johnson syndrome?
autosomal recessive. Relatively common in Iranian Jews mutation in the canalicular multidrug resistance protein 2 (MRP2) results in defective hepatic excretion of bilirubin results in a grossly black liver benign
1118
Key features of Rotor syndrome?
autosomal recessive defect in the hepatic uptake and storage of bilirubin benign
1119
Iron studies?
- serum iron - total iron binding capacity (TIBC) - transferrin saturation - ferritin - Rare= transferrin receptors increased in IDA
1120
Total iron binding capacity (TIBC)?
- transferrin - raised in iron def anaemia (IDA) - raised in preg and by oestrogen
1121
Transferrin saturation?
calculated by serum iron/TIBC
1122
Ferritin?
raised in inflam disorders and low in IDA
1123
Results of iron studies in anaemia of chronic disease?
- normo/hypochromic/, normocytic anaemia - reduced serum and TIBC - normal or raised ferritin
1124
Ischaemic hepatitis?
diffuse hepatic injury resulting from acute hypoperfusion (sometimes knows as 'shock liver'). Not inflamm process. Diagnosis= presence of inciting event eg. cardiac arrest and marked increases in aminotransferase levels (>1000 or 50x the upper limit of normal) Often occurs in conjunction with AKI (tubular necrosis) or other end-organ dysfunction.
1125
Melanosis coli?
Pigmentation of the bowel wall. Histology= pigment-laden macrophages. Associations= laxative abuse espec anthraquinone compounds eg. senna
1126
Metabolic alkalosis?
Caused by loss of H+ ions or gain of bicarbonate. Mainly due to problems of kidney or GI tract.
1127
Causes of metabolic alkalosis?
- Vomiting/aspiration: eg. peptic ulcer leading to pyloric stenos, nasogastric suction; vomiting may also lead to hypokalaemia - diuretics - liquorice, carbenoxolone - hypokalaemia - primary hyperaldosteronism - Cushing's - Bartter's syndrome
1128
Mechanism of metabolic alkalosis?
- activation of renin-angiotensin II-aldosterone (RAA) system is a key factor - aldosterone causes reabsorption of Na+ in exchange for H+ in the distal convoluted tubule - ECF depletion (vomiting, diuretics) → Na+ and Cl- loss → activation of RAA system → raised aldosterone levels - in hypokalaemia, K+ shift from cells → ECF, alkalosis is caused by shift of H+ into cells to maintain neutrality
1129
Molecular biology techniques?
- Southern blotting= detects DNA - Northern blotting= detects RNA - Western blotting= detects proteins; uses gel electrophoresis to separate native proteins by 3D structure; eg. confirmatory HIV test (SNOW DROP= (South, North, West) and (DNA, RNA, Protein) - ELISA
1130
Enzyme-linked immunosorbent assay (ELISA)?
a type of biochemical assay used to detect antigens and antibodies a colour changing enzyme is attached to the antibody if looking for an antigen and to an antigen if looking for an antibody the sample therefore changes colour if the antigen or antibody is detected an example includes the initial HIV test
1131
3 less common oesophageal disorders?
- Plummer-Vinson syndrome - Mallory-Weiss syndrome - Boerhaave syndrome
1132
Key features of Plummer-Vinson syndrome?
Triad= glossitis, iron def anaemia and dysphagia (secondary to oesophageal webs) Mx= iron supplements and dilation of the webs
1133
Key features of Mallory-Weiss syndrome?
severe vomiting -> painful mucosal lacerations at gastroesophageal junction -> haematemesis. Common in alcoholics; after many bouts of vomiting.
1134
Boerhaave syndrome?
Severe vomiting -> oesophageal rupture
1135
Peutz-Jeghers syndrome?
autosomal dominant condition characterised by numerous hamartomatous polyps in GI tract.
1136
Prognosis of Peutz-Jegers syndrome?
although polyps themselves don't have malignant potential, around 50% pts have died from another GI ca by age of 60yrs
1137
Peutz-Heghers syndrome genetics?
autosomal dominant responsible gene encodes serine threonine kinase LKB1 or STK11
1138
Peutz-Jeghers syndrome features?
hamartomatous polyps in the gastronintestinal tract (mainly small bowel) - small bowel obstruction is a common presenting complaint, often due to intussusception - gastrointestinal bleeding pigmented lesions on lips, oral mucosa, face, palms and soles
1139
Mx of Peutz-Jeghers syndrome?
Conservative unless Cx develop
1140
Pyogenic liver abscess most common organisms found?
staph aureus in children and E.coli in adults
1141
Mx of pyogenic liver abscess?
- Drainage (percutaneous) and Abx: amoxicillin + ciprofloxacin + metronidazole or if allergic: ciprofloxacin + clindamycin
1142
Scoring systems for liver cirrhosis?
- Model for End-Stage Liver Disease (MELD) is newer (particularly pts who are on liver transplant waiting list) - Child-Pugh classification is older
1143
Child-Push classification for severity of liver cirrhosis?
bilirubin, albumin, PT, encephalopathy ans ascites. Severity is A (<7), B (7-9) or C (>9)
1144
Model for End-Stage Liver Disease (MELD) scoring system for liver cirrhosis?
bilirubin, creatinine and INR to predict survival. 3 month mortality calculated based on MELD scores. particularly for pts on liver transplant list
1145
Small bowel bacterial overgrowth syndrome (SBBOS)?
XS amounts of bacteria in small bowel resulting in GI symptoms
1146
RFs for SBBOS?
- DM - neonates with congenital GI abnormalities - scleroderma
1147
CP of SBBOS?
overlap with IBS - chronic diarrhoea - bloating flatulence - abdo pain
1148
Diagnosis of SBBOS?
- hydrogen breath test - small bowel aspiration and culture: less often - may give Abx as diagnostic trial
1149
Mx for SBBOS?
- TUC - Abx= rifaximin
1150
Villous adenoma?
colonic polyps with potential for malignant transformation; secrete large amounts of mucous, potentially resulting in electrolyte disturbances
1151
Features of villous adenoma?
- most asymptomatic - non-spec lower GI symptoms - secretory diarrhoea - microcytic anaemia - hypokalaemia
1152
Whipple's disease?
rare multi-system disorder caused by Tropheryma whippelii infection. more common in middle aged men and those who are HLA-B27 +ve
1153
Features of whipple's disease?
- malabsorption: diarrhoea, weight loss - large-joint arthralgia - lymphadenopatjy - skin: hyperpigmentation and photosensitivity - pleurisy, pericarditis - neuro symptoms (rare): opthalmoplegia, dementia, seizures, ataxia, myoclonus
1154
Ix for whipple's disease?
Jujunal biopsy= deposition of macrophages containing Periodic acid-Schiff (PAS) granules
1155
Mx for whipple's disease?
guidelines vary oral co-trimoxazole for 1yr and sometimes preceded by a course of IV penicillin
1156
Wilson's disease?
autosomal recessive disorder characterised by XS copper deposition in tissues
1157
Metabolic abnormalities from Wilson's disease?
increased copper absorption from small intestine and decreased hepatic copper excretion
1158
Wilson's disease is caused by a defect in what gene/chromosome?
Defect in gene ATP7B located on chromosome 13
1159
When does the onset of symptoms in Wilson's typically occur?
between 10-25yrs
1160
First sign of Wilson's disease in children vs adults?
children= present with liver disease adults= neuro disease
1161
Features from Wilson's result from what?
XS copper deposition in tissues, espec the brain, liver and cornea.
1162
Features of Wilson's disease?
- Liver= hepatitis and cirrhosis - Kayser-Fleischer rings - Neuro= speech, behavioural and psychiatric probems - renal tubular acidosis (esp. Fanconi syndrome) - haemolysis - blue nails
1163
Neurological features of Wilson's?
- basal ganglia degeneration: in brain; most copper deposited in basal ganglia, particularly in putamen and globus pallidus - speech, behavioural and psychiatic problems often 1st manifestation - also: asterixis, chorea, dementia, parkinsonism
1164
Kayser-Fleischer rings in Wilson's?
- green-brown rings in the periphery of the iris - due to copper accumulation in Descemet membrane - present in around 50% pts with isolated hepatic Wilson's and 90% who have neuro invl.
1165
Ix for Wilson's?
- slit lamp exam for Kayser-Fleischer rings - reduced serum caeruloplasmin - reduced total serum copper - increased 24hr urinary copper excretion - diagnosis confirmed= genetic analysis of ATP7B gene
1166
Why do you get reduced total serum copper in Wilson's?
- counter-intuitive but 95% of plasma copper is carried by ceruloplasmin and in Wilson's ceruloplasmin is reduced - but free (non-ceruloplasmin-bound) serum copper is increased - also as copper accumulates in tissues there is less available in bloodstream
1167
Mx of Wilson's?
Penicillamine (chelates copper) 1st line (trientine hydrochloride is alternative chelating agent)
1168
Zollinger-Ellison syndrome?
XS levels of gastrin secondary to a gastrin secreting tumour majority of these tumours found in first part of duodenum; second most common location is the pancreas
1169
In Zollinger-Ellison syndrome, around 30% of gastrinomas occur as part of what?
MEN type I syndrome
1170
Features of Zollinger-Ellison syndrome?
- multiple gastroduodenal ulcers - diarrhoea - malabsorption
1171
Diagnosis of Zollinger-Ellison syndrome?
- Fasting gastrin levels (best screen test) - secretin stimulation test
1172
Mx of Zollinger-Ellison syndrome?
- High dose PPI (manage the extra stomach acid and help stop ulcer developing) - Curative= surgery

FINALS (37 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions