GI and Liver Flashcards
What should patients with coeliac receive every 5 years?
PCV vaccine due to hyposplenism
What should patients with spontaneous bacterial peritonitis receive?
Abx prophylaxis
Patients with raised platelets and nausea need what?
Non urgent referral for endoscopy
Management of patient with suspected upper GI bleed?
endoscopy within 24 hours of admission
What is the treatment of wilsons?
Penicillamine
Sudden onset severe abdo pain with vomiting and rapid bloody diarrhoea?
Acute mesenteric ischaemia
Raised transferrin and ferritin with low TIBC suggests what?
Haemochromatosis
Sudden onset abdo pain in someone with peptic ulcer disease?
Perforated peptic ulcer
How are perforated peptic ulcers managed?
- Erect CXR which shows free air under diaphragm
- Refer to general surgery
Tx of C diff?
- Oral vancomycin for 10 days
- If reoccurs: oral fidaxomicin
Anti-mitochondrial antibodies suggest what?
Primary Biliary Cholangitis
First line medication for PBC?
Ursodeoxycholic acid
What is associated with UC?
Primary sclerosing cholangitis
Investigation of choice for suspected pancreatic cancer?
High resolution CT
Management of liver abscess?
Percutaneous drainage with IV Abx - usually amoxicillin, ciprofloxacin and metronidazole
Vomiting followed by severe chest pain and signs of shock?
Oesophageal rupture (Boerhaave syndrome)
What cancer is associated with PSC patients?
Cholangiocarcinoma
What does pernicious anaemia predispose to?
Gastric carcinoma
Management of C diff if symptoms still ongoing after 10 days?
Oral vancomycin and IV Metronidazole
What should be measured to monitor treatment of haemachromatosis?
Transferrin saturation and serum ferritin
Management of haemachromatosis?
- Venesection
- Desferrioxamine
What should be given to patients with suspected variceal bleeding before endoscopy?
Terlipressin
Coeliac disease increased risk of which cancer?
enteropathy associated T cell lymphoma of small intestine
Diarrhoea with greasy stools in swimming pool user?
Giardia lamblia
What is SAAG (serum ascites-albumin gradient) used to measure?
- Portal HTN
- If >11, then portal HTN
How is dyspepsia managed?
- Trial of PPI for 1 month OR test and treatH pylori
- If either is unsuccessful, try the other approach
What are patients with haemochromatosis at risk of?
Hepatocellular carcinoma -> screening with US needed
sweet and fecal breath is indicative of what?
Liver failure
When should PPIs be stopped before upper GI endoscopy?
2 weeks before
Which artery is most likely to be the source of bleeding for someone with peptic ulcer disease?
Gastroduoedenal artery
Tenesmus is generally associated with which IBD?
Ulcerative Colitis
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
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
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
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
Diarrhoea, fatigue, osteomalacia?
Coeliac disease
What is carcinoid syndrome?
A condition usually when metastases are in the liver and then release serotonin into circulation
How does carcinoid syndrome present?
- Flushing
- Diarrhoea
- Bronchospasm
- Hypotension
- urinary 5-HIAA should be measured with ocreotide to treat
What is a key intervention in patients with asictes?
Restrict dietary sodium
Management of Barret’s?
High dose PPI + endoscopic surveillance
What should be avoided in patients with severe colitis?
Endoscopy -> risk of perforation -> use flexible sigmoidoscopy instead
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
fatigue, erectile dysfunction and arthralgia?
Haemochromatosis
How can haemochromatosis present?
- Bronze skin
- Diabetes
- Liver disease
- Cardiac failure secondary to dilated cardiomyopathy
- Arthritis
signet ring cells are indicative of?
Gastric adenocarcinoma
How does achalasia present?
- Dysphagia of liquids and solids
- Heartburn
- Regurgitation of food
How is achalasia investigated?
- Gold standard: Oesophageal manometry which shows excessive lower oesophageal sphincter tone
- Barium swallow shows bird’s beak appearance
How is achalasia managed?
- Pneumatic balloon dilation
- Surgical intervention: Heller cardiomyotomy
What sign may be seen in pancreatic cancer?
Double duct sign -> dilated common bile duct and dilated pancreatic duct
What does Riglers sign indicate?
- Gas in the peritoneal cavity: sign of perforation
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
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
How does acute mesenteric ischaemic be managed?
- Test serum lactate which will be raised
- Urgent surgery needed: immediate laporotomy
Severe abdo pain, sudden onset and out-of-keeping with exam findings?
Acute mesenteric ischaemia
What is ischaemic colitis?
Occlusion of blood flow to the large bowel resulting in inflammation, ulceration and haemorrhage. Acute but transient.
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.
How will ischaemic colitis be managed?
Abdo X ray - thumbprinting seen
Supportive treatment, surgery if severe
Indications for surgery in ischaemic colitis?
- generalised peritonitis
- perforation
- ongoing haemorrhage
Ix for ischaemic colitis?
abdo x-ray= ‘thumbprinting’ due to mucosal oedema/haemorrhage
How should a severe flare of UC be treated?
IV corticosteroids
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
What should be given alongside isoniazid to prevent peripheral neuropathy?
Pyridoxine (vitamin B6)
T2DM with abnormal LFTs
NAFLD
What blood test can be done alongside incidental findings of NAFLD?
Enhanced liver fibrosis test
Which drugs are used to maintain remission in Crohns?
Azathioprine or mercaptopurine
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
What is a severe complication of IBD flare up?
Toxic megacolon -> abdo X-ray needed
Which scores are used in acute GI bleeds?
- Glasgow Blatchford score to identify who can be managed as outpatient
- Rockall score done after endoscopy to identify risk of rebleeding
Alcohol units formula?
volume (ml) * ABV / 1,000
What can be given as prophylaxis for episodes of hepatic encephalopathy?
Lactulose
Metabolic alkalosis + hypokalaemia
Vomiting
Which tool is used to assess for malnutrition in patients?
MUST - malnutrition universal screening tool
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
severe, colicky post-prandial abdominal pain, weight loss, and an abdominal bruit
Intestinal angina/chronic mesenteric ischaemia
‘intestinal angina’, colickly, intermittent abdo pain with non-specific features?
chronic mesenteric ischaemia (rare clinical diagnosis)
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
Which test should be used to test for eradication of H pylori?
Urea breath test
What is the most common cause of inherited colorectal cancer?
HNPCC - hereditary nonpolyposis colorectal cancer
What are aminosalicylates associated with?
Agranulocytosis - check FBC
Pain on swallowing (odynophagia) can be a sign of what?
Oesophageal candida
What is used to determine the severity of the C diff infection?
WCC
Bleeding gums and receding
Scurvy
liver and neurological disease
Wilsons disease
Electrolyte imbalances of refeeding syndrome ?
Hypophosphataemia, hypokalaemia and hypomagnesaemia
Abdominal pain, Bloating and Change in bowel habit
IBS
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
Which drugs can cause cholestasis?
- COCP
- Abx including flucloxacillin, co-amoxiclav
Coeliac disease is associated with deficiency of what?
iron, folate and vitamin B12 deficiency
Which IBD is associated with gallstones?
Crohns
What is used to assess whether glucocorticoid therapy may be beneficial in alcoholic hepatitis?
Maddreys function - serum bilirubin and prothrombin time
Antinuclear antibodies, anti-smooth muscle antibodies and raised IgG levels
Autoimmune hepatitis
dysphagia, glossitis and iron-deficiency anaemia
Plummer-Vinson syndrome
watery green diarrhoea post cholecystectomy
Bile acid malabsorption -> treat with cholestyramine
What is decreased in Wilsons disease?
serum caeruloplasmin
Haemochromatosis is a cause of what?
Hypogonadotropic hypogonadism
Patients with a suspected GI bleed require what?
OGD within 24 hours
What LFTs can indicate pancreatic cancer?
Cholestatic picture
What is an unreliable indicator of iron stored in the body during illness?
Ferritin -> use transferrin saturation instead
What can be used to differentiate between and upper and lower GI bleed?
Urea levels - high in upper GI bleed
Investigations for PSC?
- US scan
- MRCP
What is used for prophylaxis of oesophageal bleeding?
Propranolol
Management of severe alcoholic hepatitis?
Steroids
Which cancers are associated with HNPCC?
- Colorectal
- Endometrial
- Ovarian
- Pancreatic
What is the treatment of hypophosphatemia?
Intravenous infusion of phosphate polyfusor
Most common organism causing SBP?
Gram negs - E coli, Klebsiella
Management of Dysplasia on biopsy in Barrett’s oesophagus
Endoscopic intervention
What should you test to screen for haemochromatosis?
Transferrin saturation
Psychosis is a complication of what?
Wilsons disease
What is the investigation of choice for perianal fistulae in Crohns?
MRI
Bleeding vs perforated peptic ulcer?
Perforated ulcer should present with signs of peritonitis e.g. abdo pain, distension, guarding
Deranged LFTs and AKI in someone with septic shock?
Think ischaemic hepatitis
Patients allergic to aspirin may also react with what?
Sulfasalazine
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)
What should be given for prophylaxis of variceal bleeds?
Propranolol
Management of SBP
Acute: IV Cefotaxime
Abx prophylaxis if they have ascites: Ciprofloxacin until ascites resolves
Back pain worse on lying down, appetite loss and weight loss
Pancreatic cancer
What is the most common type of oesophageal malignancy in patients with GORD?
Adenocarcinoma
What can cause a wheeze in people with GORD?
Inhalation of small amounts of gastric contents
What is the gold standard investigation for GORD?
Oesophageal pH manometry
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
What is a complication of Nissen fundoplication?
Dysphagia from compression of the junction
Examination signs of chronic liver disease
- Clubbing
- Palmar erythema
- Dupuytren’s contracture
- Hepatosplenomegaly
- Ascites
What are complications of liver cirrhosis?
- Encephalopathy
- Sepsis
- SBP
- Ascites
- Varices
What dietary advice would you give someone with ascites?
- Fluid restriction
- Low sodium
Why is lactulose given in encephalopathy?
Reduce number of nitrogen producing bacteria in the gut which contribute to hepatic encephalopathy
Why can anti-EMA antibodies be negative in severe malabsorption in coeliac?
Deficiency in proteins such as IgA
Haematemesis + distended abdomen
Variceal bleeding
What is an indicator of pancreatitis severity?
Hypocalcaemia
What is the most common cause of large bowel obstruction?
Tumour then volvulus/diverticular disease
What do Hepatitis B serology markers mean?
HBSAg - acute infection (if > 6 months then chronic infection)
Anti-HBs - immunity
Anti-HBc - previous/current infeection
Causes of different types of jaundice
Pre - Sickle cell, G6PD, Hereditary spherocytosis
Hepatic - Hepatitis, PBC, PSC, EPV, HCC
Post hepatic - biliary atresia, gallstones, pancreatitis
Stages of liver disease
Steatosis -> Fibrosis/Steatohepatitis -> Cirrhosis
When is liver transplant indicated in liver disease?
In chronic liver disease, patients must have stopped alcohol for atleast 6 months
What are complications of GORD?
- Barret’s
- Adenocarcinoma
- Oesophageal stricture
- Chronic cough
What are complications of UC?
- Colon cancer
- Toxic megacolon
- Bowel perforation
Where does volvulus cause large bowel obstruction?
Sigmoid
What is coffee bean sign indication of?
Sigmoid volvulus
What is the management of sigmoid volvulus?
Stable - rigid sigmoidoscopy with flatus tube insertion
Unstable - Urgent laparotomy
Palpable fullness in the gallbladder with painless jaundice?
Think pancreatic cancer
Fever, abdo pain, cirrhosis and portal HTN?
Think SBP
Hypertrophic pulmonary osteoarthropathy is associated with what?
Squamous cell carcinoma of lung
Achalasia increases the risk of what?
Squamous cell carcinoma of the oesophagus
What is the best way to assess someone response to Hep C treatment?
Viral load
Ongoing jaundice + pain post cholecystectomy?
Gallstone in common bile duct
Management of malignant distal obstructive jaundice due to unresectable pancreatic carcinoma
Biliary stenting
Flu like illness with RUQ pain, tender hepatomegaly and deranged LFTs?
Think Hep A
What would biliary colic blood show?
Everything normal
What should you not do in someone with suspected pancreatitis?
Make them nil by mouth - enteral feeding should be offered
What is the treatment for symptomatic perinala fistulae in Crohn’s?
Oral metronidazole
History of vascular disease and lactic
acidosis
Think mesenteric ischaemia
What is the most sensitive/specific test for pancreatitis?
Lipase
What is the marker of choice to assess liver synthetic function?
INR (prothrombin time)
What are some components of Child-Pugh score?
- Bilirubin
- Albumin
- PT
- Encephalopathy
- Ascites
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
What are the components of Glasgow score for pancreatitis?
Pa02
Age > 55
Neutrophils
Calcium < 2
Renal function
Enzymes
Albumin
Sugar
Why is US scan helpful in pancreatitis?
Assess for presence of gallstones
What are the 2 signs of pancreatitis?
Grey Turners - Bruising along flanks suggestive of haemorrhagic pancreatitis (sign of retroperitoneal bleeding)
Cullen - Bruising around umbilicus
Pigmented gallstones are associated with what?
Sickle cell anaemia
pseudomembranous colitis is what?
C diff colitis
What is the treatment for cholecystitis?
IV Abx with laparoscopic cholecystectomy within 1 week of diagnosis
What can be used to manage complex anal fistulae?
Draining seton
What is the most common disease pattern in UC and Crohns?
UC - Proctitis
Crohns - Ileitis
What drugs should be stopped in C diff infection?
Opioids
anorectal pain and a tender lump on the anal margin
Thrombosed haemorrhoids
short incubation period and severe vomiting
Staph aureus gastroenteritis
Which Abx can be used for Campylobacter infection if severe/immunocompromised?
Clarithromycin
Charcot’s triad plus hypotension and confusion
Reynolds pentad
What is necessary before a diagnosis of PBC?
Imaging to exclude a extrahepatic biliary obstruction
Management of acute anal fissues?
Bulk forming laxatives
What is Troisier’s sign?
Enlarged hard left supraclavicular lymph node which indicates metastatic abdo malignancy
What are risk factors for gastric cancer?
- H pylori
- Gastric polyps
- Pernicious anaemia
- Gastric ulceration
What does TNM staging assess?
Size of tumour
Presence of lymph nodes
Evidence of metastases
What is the marker for HCC?
AFP
Surgical procedures for pancreatic cancer?
- Pancreaticoduodenectomy
- Whipples
flu-like symptoms, RUQ pain, tender hepatomegaly and deranged LFTs
Hepatitis A
Hepatitis serology
IgM - acute infection
IgG - chronic infection
Severe hepatitis in a pregnant woman
Hep E
Man returns from trip abroad with maculopapular rash and flu-like illness
Think HIV seroconversion
Undercooked pork?
Hepatitis E
Right-sided tenderness on PR exam
Acute appendicitis
What is the surgery for bilateral/recurrent inguinal hernias?
Laparoscopic repair with mesh
Mesalazine can cause what?
Drug induced pancreatitis
lemon tinge to the skin
Pernicious anaemia
pH < 7.3 at 24 hours post paracetamol overdose?
Liver transplant consideration
periodic acid-Schiff- (PAS-) positive macrophages
Whipples disease
dysphagia, iron deficiency anaemia and glossitis
Plummer Vinson syndrome
What is a TIPS procedure?
Artifical channel within the liver used for variceal bleeding refractory ascites
Major complication is hepatic encephalopathy
severe abdominal pain, ascites and tender hepatomegaly
Budd-Chiari syndrome
Which laxative to prescribe when starting patients on opiates?
Senna
Management of diverticulitis flare?
Oral Abx with admission to hospital if symptoms do not improve within 72 hours
Why give albumin for large volume ascites?
reduce paracentesis-induced circulatory dysfunction and mortality
What is usually normal with acute cholecystitis?
LFT tests
classic epigastric pain which is relieved on sitting forwards
Think chronic pancreatitis
What will AST:ALT ratio be in alcoholic hepatitis?
2:1
caput medusae and splenomegaly in a known alcoholic suggest what?
Portal HTN
Antibodies for PBC
Anti-mitochondrial - most common
Anti-smooth muscle
What does a score of 3 or more on Glasgow criteria suggest for pancreatitis?
May need ITU input
slate-grey skin pigmentation
Haemochromatosis
Diarrhoea after rice?
Bacillus cereus
What are the anti emetics of choice in gastroparesis?
- Metoclopramide
- Domperidone
fever, malaise, abdo pain and rose spots on trunk?
Typhoid fever -> treat with fluids and Ciprofloxacin
Raised ALP and bilirubin suggests what?
Cholestatic picture
What marker is raised in cholangiocarcinoma?
CA19-9
MSH2/MLH1 mutation?
HNPCC
What is the AST:ALT ratio in alcoholic liver disease?
2:1 - AST 2 times higher than ALT
Gastroenteritis incubation periods?
1-6 hours: Staph aureus
12-48 hours: Salmonella, E coli
48-72 hours: Shigella, Campylobacter
>7 days: Giardiasis, Amoebiasis
mural thickening of the colon and the presence of pericolic fat stranding in the sigmoid colon
Diverticular disease
What is the weight loss definition for malnutrition?
Loss of >10% in the last 3-6 months
What should the prothrombin time be in order to qualify for liver transplant?
> 100seconds
First line test for coeliac in GP?
Total IgA and IgA tissue transglutaminase
When should a repeat endoscopy be done after the start of PPI therapy for ulcer?
6-8 weeks
Autoimmune hepatitis antibodies?
Type 1 - ANA, anti-smooth muscle
Type 2 - Anti-LKM-1
What can help to confirm SBP from Ascitic fluid?
Raised neutrophils
triad of vomiting, pain and failed attempts to pass an NG tube
Gastric volvulus
Post prandial vomiting and abdo pain in someone with chronic pancreatitis?
Pancreatic pseudocyst
Blockage where does not cause jaundice?
Cystic duct or gallbladder
ALT/AST in the 10,000s?
Think paracetamol overdose
AST vs ALT
AST - alcohol overdose
ALT - drug overdose/viral hepatitis
Suspected cholecystitis in GP?
Refer to hospital for urgent admission
spiral or comma-shaped gram negative
Campylobacter
Ischaemia to the lower GI tract can result mainly into what 3 conditions?
1) acute mesenteric ischaemia
2) chronic mesenteric ischaemia
3) ischaemic colitis
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
Predisposing factors to bowel ischaemia?
age, AF, smoking, HTN, DM, cocaine, other causes of emboli eg. endocarditis, malignancy
What is sometimes seen in young pts following cocaine use?
ischaemic colitis
Typical common features of bowel ischaemia?
abdo pain, rectal bleeding, diarrhoea, fever, elevated WBC associated with lactic acidosis
What do blood for bowel ischaemia show?
Elevated WBC associated with lactic acidosis
Ix for bowel ischaemia?
CT
Boerhaaves syndrome?
spontaneous rupture of oesophagus that occurs as a result of repeated episodes of vomiting; rupture usually left side and distal
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
Diagnosis of Boerhaaves syndrome (spontaneous rupture of oesophagus)?
CT contrast swallow
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
Appendicitis?
Acute inflam of appendix (small narrow tube connected to the caecum)
Causes of appendicitis?
- luminal obstruction (50%)
- unknown
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
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
Peak incidence of appendicitis?
2nd and 3rd decade of life
Appendicitis can be characterised as what?
Uncomplicated (non-perforating) or complicated (perforating)
Cx resulting from delay or misdiagnosis of appendicitis?
perforation: abscess formation, peritonitis, sepsis, intra-abdo adhesions, bowel obstruction
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
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
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
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
Possible post-op Cx from appendicectomy?
small bowel obstruction, superficial wound infection, intra-abdo abscess, stump leakage, stump appendicitis
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
3 specific signs for acute appendicitis?
- Rovsing’s sign
- Psoas sign
- Obturator sign
Appendicitis: Rovsing’s sign?
palpation of left lower quadrant increased pain felt in right lower quadrant
Appendicitis: Psoas sign?
passive extension of right thigh with pt in left lateral position elicits pain in right lower quadrant
Appendicitis: Obturator sign?
passive internal rotation of flexed right thigh elicits pain in RLQ
How may appendicitis present in infants and young children?
non-specific abdo pain and anorexia, may appear withdrawn
How may elderly pts present with appendicitis?
minimal pain or fever, may present with acute confusion or shock
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
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
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
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
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
Ix to exclude alternative cause in suspected appendicitis?
- FBC: neutrophil predominant and leucocytosis
- CRP: raised or normal
- Urine dip: exclude UTI
- Pregnancy test
What pts are most likely to be diagnosed with appendicitis clinically?
thin male
Acute cholecystitis?
Inflamm of gallbladder, usually when gallstone completely obstructs gallbladder neck or cystic duct
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)
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.
Without treatment, what happens to pt with acute cholecystitis?
May resolve spontaneously within 1-7days; 25-30% will need surgery
Cx of acute cholecystitis?
- gangrenous cholecystitis (necrosis of gallbladder wall)
- perforation of gallbladder
- biliary peritonitis
- pericholecystic abscess
- fistula (between GB and duodenum)
- Jaundice
- Sepsis
Why may pt with acute cholecystitis develop jaundice?
Due to inflam of adjoining biliary ducts- Mirizzi’s syndrome
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
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
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
When can pt get referred pain in acute cholecystitis?
Right shoulder or interscapular region
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)
RFs for acute cholecystitis?
- recent illness
- trauma
- female
- age
- obesity
- lower fibre diet
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
Murphy’s sign in acute cholecystitis?
inspiration is inhibited by pain on palpation when hand is positioned along costal margin; unreliable in older pts
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.
Differential diagnosis for acute cholecystitis?
- acute cholangitis
- ACS
- acute pancreatitis
- appendicitis
- GI cancer
- GORD
- hepatitis
- peptic ulcer
- right lower lobe pneumonia
- symptomatic gallstones
LFTs in acute cholecystitis?
typically normal; if deranged may indicate Mirizzi syndrome
Ix for acute cholecystitis?
USS first line
Treatment for acute cholecystitis?
IV Abx + early laparoscopic cholecystectomy within 1w of diagnosis
Conditions associated with biliary stasis or thickening?
sepsis, extensive trauma, burns, major surgery, prolonged fasting
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
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
Classification of severity of acute pancreatitis?
Mild, moderatley severe, severe, recurrent
Mild acute pancreatitis?
absence of local or systemic Cx or organ failure; uneventful recovery and resolves in first week. MOST COMMON
Moderately severe acute pancreatitis?
local Cx and/or transient organ failure that resolves within 48hrs
Severe acute pancreatitis?
persistent single or multiorgan failure for >48hrs
Recurrent acute pancreatitis?
occurs on more than once occasion with full recovery between episodes
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
Local Cx of acute pancreatitis?
pancreatic necrosis, pseudocyst, abscess, fistulae, thrombosis, haemorrhage
Systemic Cx of acute pancreatitis?
multiorgan failure and sepsis, AKI, acute resp distress syndrome
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
Mx for suspected acute pancreatitis?
- emergency hospital admission for specialist assessment and Mx
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
Signs of shock? eg. in acute pancreatitis
tachycardia, tachypnoea and hypotension
What signs are sometimes associated with complicated haemorrhagic pancreatitis (rare)?
- Cullen’s sign
- Grey-Turners sign
- Fox’s sign
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)
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
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
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)
Should you follow up pt with acute pancreatitis?
If have confirmed diagnosis and been discharged from hospital
- advice and support
- Mx RFs
Pathophysiology of pancreatits?
autodigestion of pancreatic tissue by prematurely activated pancreatic enzymes leading to necrosis
What condition may show Cullen’s sign (periumbilical discolouration) and Grey-Turner’s sign (flank discolouration) but is rare?
Acute pancreatitis
Rare features associated with pancreatitis?
ischaemic (Purtscher) retinopathy: may cause temp or permanent blindness
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
Is serum lipase useful in acute pancreatitis?
more sensitive and specific than amylase, has long half-life so useful for late presentations >24hrs
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
Specific scoring systems for acute pancreatitis?
Glasgow score; Ranson score and APACHE II
Common factors that may indicate severe pancreatitis?
- > 55yrs
- hypocalcaemia
- hyperglycaemia
- hypoxia
- neutrophilia
- elevated LDH and AST
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
Drugs that may cause acute pancreatitis?
azathioprine, mesalazine, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valporate
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
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
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
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
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.
Alcoholic liver disease covers a spectrum of what conditions?
- alcoholic fatty liver disease
- alcoholic hepatitis
- cirrhosis
Ix for alcoholic liver disease?
- gamma-GT elevated
- AST:ALT is normally >2, a ratio of >3 is suggestive of acute alcoholic hepatitis
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)
Cirrhosis?
Progressive liver disease due to chronic inflam of liver, usually over 1-20yrs
What happens in liver cirrhosis?
normal liver structure becomes distorted with regenerative nodules surrounded by diffuse fibrosis, affecting synthetic, metabolic and excretory actions
Types of cirrhosis?
Compensated cirrhosis and decompensated cirrhosis
When does a transition from compensated to decompensated cirrhosis occur in some people?
Due to the development of portal HTN and/or hepatocellular dysfunction
Compensated cirrhosis?
inital largely asymptomatic phase when liver still functions effectively
Decompensated cirrhosis?
symptomatic phase with potentially life-threatening Cx eg. jaundice, ascites, hepatic encephalopathy and/or variceal bleeding
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
Cx of cirrhosis?
- malnutrition and frailty
- osteoporosis
- infection & sepsis incl. spontaneous bacterial peritonitis
- jaundice
- ascites
- hepatic encephalopathy
- variceal bleeding
- AKI
- hepatorenal syndrome
- heptatocellular carcinoma
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
Symptoms of chronic liver disease eg. in cirrhosis?
abnom bruising, bleeding or itch
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
Signs of decompensation in cirrhosis?
jaundice, peripheral oedema, ascites, hepatic encephalopathy
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
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
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
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
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
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
?cirrhosis and known hep B infection?
refer gastro
?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
?cirrhosis and pt obese and/or DMT2?
do not offer tests to diagnose cirrhosis unless they have NAFLD and advanced liver fibrosis
?cirrhosis in pt with additional liver (eg. PBC, PSC, haemochromatosis, Wilson’s)?
liase with pt’s specialist or refer to heapto/gastro
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
Anal fissure?
tear or ulcer in squamous lining of distal anal canal which causes pain on defecation
How are anal fissures classifed?
- acute= <6w
- chronic= 6w+
- primary= no clear underlying cause
- secondary= clear underlying cause
Underlying causes of anal fissure?
- unknown
- constipation, IBD, STI, colorectal ca
Peak incidence of anal fissure?
15-40yrs; primary uncommon in elderly so warrant further Ix
CP of anal fissure?
- anal pain with defacation, - with or without bright red rectal bleeding
- tearing sensation on passing stool
- anal spasm
External examination of the anus may reveal what if a pt has anal fissure?
linear split in anal mucosa
Examination findings of acute anal fissure?
superficial with well-demarcated edges
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
Exam findings of primary anal fissure?
posterior midline, but 10% occur anteriorly (esp women)
Exam findings of secondary anal fissure?
irregular outline, multiple or occur laterally
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
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
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
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
When should specialist advice be sought in children with anal fissure?
if not healed after 2w or sooner if signif pain
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
Ascending cholangitis?
Bacterial infection (typically E.coli) of biliary tree
Most common predisposing factor for ascending cholangitis?
gallstones
Charcot’s triad occurs in 20-50% pts with what?
ascending cholangitis
Ascending cholangitis: Charcot’s triad?
RUQ pain
Fever
Jaundice
Ascending cholangitis: Reyonold’s pentad?
RUQ pain
Fever
Jaundice
+
hypotension and confusion
Feature of ascending cholangitis?
- fever, RUQ pain, jaundice, hypotension, confusion
- raised inflam markers
Ix for ascending cholangitis?
USS first like= bile duct dilation and bile duct stones
Mx for ascending cholangitis?
IV Abx + Endoscopic retrograde cholangiopancreatography (ERCP) after 24-48hrs to relieve any obstruction
Ascites?
Abnormal accumulation of fluid in abdomen
Causes of ascites can be grouped into what?
a gradient of <11g/L or a gradient >11g/L
What does SAAG mean?
Serum-Ascites Albumin Gradient= calculation to determine cause of ascites.
SAAG= Serum Albumin - Ascitic Fluid Albumin
SAAG ≥ 11 g/L meaning in ascites?
ascites is due to portal hypertension
SAAG <11g/L meaning in ascites?
ascites due to causes other than portal hypertension
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
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
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
Large volume paracentesis for the treatment of ascites requires what?
Albumin ‘cover’; this reduces paracentesis induced circulatory dysfunction and mortality
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
Biliary colic?
Colicky RUQ abdo pain caused by gallstones passing through the biliary tree
RFs for biliary colic and gallstone related disease?
Fat
Female
Fertile (pregnancy)
Forty
DM, crohns, rapid weight loss (eg. weight reduction surgery), drugs
Why is obesity a RF for biliary colic?
enhanced cholesterol synthesis and secretion
Why is female a RF for biliary colic?
oestrogen increases activity of HMG-CoA reductase so gallstones 2-3x more common in women
What drugs are RFs for biliary colic?
fibrates, COCP
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
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
Where may biliary colic pain radiate?
R shoulder and interscapular region
Ix for biliary colic (gallstone disease)?
abdo USS and LFTs
if not detected on USS but high suspecion then MRCP or endoscopic USS (EUS)
Mx for biliary colic (gallstone disease)?
referral for elective laparoscopic cholescystectomy
Why may some pts with gallstones experience ongoing jaundice and pain after cholecystectomy?
gallstones may be in the common bile duct (choledocholithiasis)
Cx of gallstones?
- biliary colic
- acute cholecystitis (common)
- ascending cholangitis
- acute pancreatitis
- gallstone ileus
- gallbladder ca
Choledocholithiasis?
Gallstone in common bile duct
Cholelithiasis?
Gallstones
What is a gallstone (cholelithiasis)?
solid deposit that forms within gallbladder
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
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
Cholesterol gallstone formation is a result of what 3 defects?
cholesterol supersaturation, accelerated cholesterol crystal nucleation and impaired gallbladder motility
What type of diet is associated with gallstones?
high in triglycerides and refined carbs and low in fibre
What medication is associated with gallstones?
somatostatin analogues, glucagon-like peptide-1 analogues and ceftriaxone
Is treatment needed for pts with asymptomatic gallstones found in normal gallbladder and with a normal biliary tree?
No
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
When should urgent referral be made for pt with known gallstones?
known gallstones + jaundice or if suspicion of biliary obstruction eg. signif abnormal LFTs
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
Cholestasis?
blockage to flow of bile
Cholecystitis?
inflam of gallbladder
Cholangitis?
inflam of bile ducts
gallbladder empyema?
pus in gallbladder
cholecystectomy vs cholecystostomy?
cholecystectomy= surgical removal of gallbladder
cholecystostomy= inserting drain into gallbladder
Most gallstones are made from what?
cholesterol
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.
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.
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.
What is ALT and AST?
Alanine aminotransferase and aspartate aminotransferase.
Enzymes produced in the liver.
Markers of hepatocellular injury (damage to liver cells).
ALT and AST slightly high, with a higher rise in ALP?
obstructive picture eg. gallstones
ALT and AST high compared with ALP?
hepatitic picture (hepatocellular injury)
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
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
Coeliac disease?
chronic immune mediated systemic disorder in genetically predisposed people, triggered by exposure to dietary gluten.
What is gluten?
major complex protein component of wheat, barley and rye
Non-responsive coeliac disease?
persistent symptoms and enteropathy that do not respond after 6-12m on self-reported gluten-free diet
Refractory coeliac disease?
persistent or recurrent symptoms and villous atrophy on duodenal biopsy, despite strict adherence to gluten-free diet for at least 12m
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
What malignancy are pts with undiagnosed, untreated or undertreated coeliac diease at higher risk for?
Lymphoma and small bowel adenocarcinoma
Conditions associated with coeliac disease?
- DMT1
- autoimmune thyroid disease
- autoimmune liver disease
- selective IgA def
- first degree relative affected
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
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
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
What should pt do before coeliac serology testing?
ensure eaten gluten-containing foods for min 6w before testing
Mx for coeliac disease?
- education and supporrt
- long-term gluten free diet
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
When to refer pt with coeliac disease to appropriate specialist?
if non-responsive or refractory disease or serious Cx
What to give coeliac pts who have hyposplenism?
influenza, meningococcal and pneumococcal immunisation (P booster every 5yrs)
Signs and symptoms of coeliac disease are what?
non-specific and may present with intestinal and extra-intestinal manifestations or be asymptomatic.
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
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.
2 possible extra-intestinal manifestations of coeliac disease?
Aphthous ulcers
Dermatitis herpetiformis
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)
Equivocal coeliac serology result?
- adults= if IgA and tTGA equivocal do anti-EMA antibodies
- children= refer to paeds gastro
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
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
Annual blood monitoring for coeliac disease (consider)?
- coeliac serology (adherence)
- FBC & ferritin
- TFTs
- LFTs
- calcium, vit D, vit B12 and folate
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
In coeliac disease, repeated exposure to gluten causes what?
villous atrophy which causes malabsorption
Genetic association in coeliac disease?
HLA-DQ2 and DQ8
What does duodenal biopsy +ve for coeliac disease show?
- villous atrophy
- crypt hyperplasia
- increase in intraepithelial lymphocytes
- lamina propria infiltration with lymphocytes
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.
Does villous atrophy and immunology in coeliac disease reverse on a gluten free diet?
Yes
Diverticula?
sac-like protrusions of mucosa through muscular wall of colon
Diverticula occur where in around 80% of people >85yrs?
sigmoid colon
Diverticulum formation may be associated with what?
low-fibre diet
Majority of people with diverticula have symptoms where?
Left lower abdo.
Minority eg. Asian may be sided sided.
Diverticulosis?
Condition where diverticula are present without symptoms.
What may diverticulosis present with?
Large, painless rectal bleed or found incidentally during Ix for other symptoms.
Diverticular disease?
Condition where diverticula cause symptoms eg. intermittent lower abdo pain, without inflammation and infection.
Diverticulitis?
Condition where diverticula become inflamed and infected.
Diverticulitis CP?
intermittent lower left quadrant abdo pain, fever, malaise, change in bowel habit and occasionally rectal bleeding
Uncomplicated diverticulitis?
Diverticular inflam that does not extend to the peritoneum
Complicated diverticulitis?
diverticulitis associated with Cx such as abscess, peritonitis, fistula, obstruction or perforation
Risk of diverticula increases with…
age
rare <40yrs
Mx for confirmed diverticulosis?
- bulk forming laxatives if constipation
- balanced high fibre diet
- exercise, stop smoking
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
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.
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
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)
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
Example of an antispasmodic?
mebeverine
Oral Abx for acute uncomplicated diverticulitis if systemically unwell?
co-amoxiclav 500/125mg 3x daily for 5d
or cefalexin 500mg twice daily for 5d
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
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
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
Peptic ulcer disease includes what?
Gastric or duodenal ulcers
Peptic ulcer disease?
breach in the epithelium of gastric or duodenal mucosa, which is confirmed on endoscopy
Most common RFs for development of peptic ulcer disease?
Helicobacter pylori infection and NSAIDs/aspirin
Cx of peptic ulcer disease?
haemorrhage, perforation, gastric outlet obstruction
Ix of peptic ulcer disease?
- H.pylori test
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
