GI and Liver Flashcards
What is the aetiology of GORD?
Hiatus hernia, obesity, pregnancy, Zollinger-Ellison syndrome, hypercalcaemia, scleroderma and systemic sclerosis, smoking, drugs - antimuscarinics, CCB and nitrates
What is the pathophysiology involved in GORD?
Antireflux mechanisms fail, allowing gastric contents to make contact with the lower oesophageal mucosa. the sphincter relaxes independently of a swallow
What are the symptoms of GORD?
Heartburn aggravated by bending, stooping or lying down, regurgitation, nausea, chest pain and coughing
What are the signs of GORD?
Reflux pain that radiates to the arms, is relieved by antacids and is worse with hot drinks or alcohol
What tests are used to diagnose GORD?
OGD, barium meal, fully history and examination, 24-hour intraluminal monitoring
What is the treatment for GORD?
PPIs e.g. omeprazole, lansoprazole
Lifestyle measures e.g. smoking cessation, weight loss
Anti-reflux surgery
What complications can arise from GORD?
Peptic stricture
Barrett’s oesophagus
What is the aetiology of a Mallory-Weiss tear?
Increased abdominal pressure e.g. retching, vomiting, coughing, straining or even hiccuping.
What are some risk factors for a Mallory-Weiss tear?
Alcohol excess, gastroenteritis, bulimia, hepatitis
What is the pathophysiology involved in a Mallory-Weiss tear?
Increased abdominal pressure causes a linear mucosal tear resulting in bleeding, most bleeds are minor
What are the symptoms of a Mallory-Weiss tear?
Haematemesis following retching or vomiting, malaena, light-headedness, dizziness or syncope, abdominal pain, features associated with the cause of vomiting
What are the signs of a Mallory-Weiss tear?
No specific physical signs
What tests are used to diagnose a Mallory-Weiss tear?
OGD to visualise the tear
Bloods: FBC, coagulation studies and platelets, U&Es, renal function, cardiac enzymes (if MI suspected)
ECG (if MI suspected)
What is the treatment for a Mallory-Weiss tear?
ABCDE if the patient has lost a large volume of blood
Stop bleeding with endoscopic techniques.
Most patients stop bleeding spontaneously
What is the aetiology of a peptic ulcer?
H. pylori, NSAIDs, pepsin, smoking, alcohol, bile acids, steroids, stress, changes in gastric mucin consistency
What is the pathophysiology involved in a peptic ulcer?
There is an imbalance between factors that can damage the mucosal lining and defense mechanisms resulting in a break in the superficial epithelial cells penetrating down to the muscularis mucosa
What are the symptoms of a peptic ulcer?
Epigastric pain, nausea, burping, bloating, distension, heartburn, pain radiating to the back if the ulcer is posterior, symptoms relieved by antacids
What are the signs of a peptic ulcer?
Epigastric tenderness, anorexia and weight loss, succession splash if gastric emptying is slow
What tests are used for diagnosing a peptic ulcer?
Testing for H. pylori e.g. breath test or stool antigen test
Bloods: FBC
Endoscopy if there are any “red flags” or the patient >55 at first presentation
What is the treatment of a peptic ulcer?
If H. pylori positive: treat with 2 antibiotics and a PPI e.g. omeprazole, clarithromycin and amoxicillin
Behaviour modification e.g. smoking cessation, stop NSAIDs
PPIs or H2 receptor antagonists e.g. ranitidine
What are some possible complications of a peptic ulcer?
Haemorrhage, perforation, gastric outlet obstruction
What is the aetiology of gastro-oesophageal varices?
Any cause of portal hypertension.
Can be pre-hepatic e.g. portal vein obstruction
Intrahepatic e.g. cirrhosis
Posthepatic e.g. compression due to a tumour
What is the pathophysiology involved in gastro-oesophageal varices?
Portal hypertension means collateral circulation develops in the lower 1/3 of the oesophagus, abdominal wall, stomach and rectum. The small blood vessels become thin walled.
What are the symptoms of gastro-oesophageal varices?
Haematemesis, malaena, abdominal pain, features of liver disease and an underlying condition, dysphagia, confusion secondary to encephalopathy
What are the signs of gastro-oesophageal varices?
Peripherally shut down, pallor, hypotension, tachycardia, reduced urine output, malaena, signs of chronic liver disease, reduced GCS, signs of sepsis
What tests are used to diagnose gastro-oesophageal varices?
Endoscopy CXR Ascitic tap if suspected SBP Bloods: FBC, U&Es, LFTs, clotting screen, group and save, renal function, Investigate underlying cause
What is the treatment of gastro-oesophageal varices?
ABCDE if bleeding acutely and large volumes
Endoscopic band ligation, terlipressin, antibiotic prophylaxis
What is the aetiology of achalasia?
Unknown
Autoimmune, neurodegenerative and viral aetiologies have been implicated
What is the pathophysiology involved in achalasia?
There is oesophageal aperistalsis and impaired relaxation of the lower oesophageal sphincter. Histology shows inflammation of the myenteric plexus of the oesophagus with a reduction in ganglion cell numbers
What are the symptoms of achalasia?
Dysphagia, regurgitation, heartburn, chest pain - retrosternal
What are the signs of achalasia?
Rarely, there may be signs of aspiration pneumonia
What tests are used to diagnose achalasia?
CXR - dilated oesophagus behind the heart
Barium swallow - oesophagus is dilated, contrast media passes slowly into the stomach
OGD
Manometry of the oesophagus - high resting pressure in the cardiac sphincter, incomplete relaxation on swallowing and absent peristalsis
What is the treatment for achalasia?
Heller myotomy, pneumatic dilatation of the oesophagus, endoscopic injection of botulinum toxin
What complications are associated with achalasia?
Aspiration pneumonia, GORD or perforation due to treatment, oesophageal cancer (SCC)
What is the aetiology of gastritis?
H. pylori infection, autoimmune causes, viruses e.g. CMV or HSV, duodenogastric reflux or Crohn’s disease
What is the pathophysiology of gastritis?
Inflammation is associated with mucosal injury, inflammation can be acute or chronic. Mucous gland metaplasia occurs in the setting of severe damage of the gastric glands.
What are the symptoms of gastritis?
Epigastric pain (can be dull, vague, burning, aching, gnawing, sore or sharp), nausea, vomiting, burping, bloating, early satiety, loss of appetite
What are the signs of gastritis?
No specific physical signs
What tests are used to diagnose gastritis?
History and examination Bloods - FBC, LFTs, U&Es, CRP and ESR Urinalysis Stool - faecal occult blood Xrays ECG - rule out cardiac cause of pain OGD Breath test for H. pylori infection
What is the treatment for gastritis?
H. pylori eradication - 2 antibiotics and a PPI
Antacids
PPIs (e.g. omeprazole)
H2 receptor antagonists (e.g. ranitidine)
Stop NSAID medications
What is the aetiology of coeliac disease?
Coeliac is caused by a reaction to gliadin, a gluten protein found in wheat and similar proteins found in other crops. Infection by rotavirus or human intestinal adenovirus are thought to make people susceptible to coeliac disease.
What is the pathophysiology of coeliac disease?
The inflammatory process mediated by T cells leads to disruption of the structure and function of the small bowels mucosal lining - villous atrophy and crypt hyperplasia.
What are the symptoms of coeliac disease?
Diarrhoea, steatorrhoea, abdominal discomfort, bloating or pain, weight loss, mouth ulcers
What are the signs of coeliac disease?
Angular stomatitis, peripheral oedema, osteoporosis, increased incidence of atopy and autoimmune disorders e.g. Sjogren’s syndrome
Signs related to anaemia e.g. pallor, malaise, fatigue
What tests are used to diagnose coeliac disease?
Endoscopy and small bowel biopsy - gold standard
Bloods: FBC, U&Es, LFTs, endomysial and tissue transglutaminase antibodies, B12 levels, folate, ferritin, calcium, albumin
DEXA scans for signs of osteoporosis
Stool - faecal calprotectin
What is the treatment for coeliac disease?
Lifelong, strict, gluten free diet
Vitamin supplements if the patient is deficienct
What complications can arise from coeliac disease?
There is an increased risk of malignancy, intestinal lymphoma especially
What is the aetiology of Crohn’s disease?
The exact aetiology is unknown, it is thought to be a combination of genetic susceptibility, environmental factors and host immune responses. Smoking increases the risk and NSAIDs may exacerbate the condition.
What is the pathophysiology involved in Crohn’s disease?
Transmural granulomatous inflammation and skip lesions are characteristic of Crohn’s disease, ulceration can be an outcome of highly active disease. It favours the terminal ileum but can affect anywhere from mouth to anus.
What are the symptoms of Crohn’s disease?
Diarrhoea, abdominal pain, weight loss, fever, malaise, anorexia
What are the signs of Crohn’s disease?
Clubbing, mouth ulcers, erythema nodosum, pyoderma gangrenosum, iritis, conjunctivitis, episcleritis, large joint arthritis
What tests are used to diagnose Crohn’s disease?
Bloods: FBC, ESR, CRP, U&Es, LFTs, folate and iron, serology
Stool - MC&S, CDT and faecal calprotectin
Sigmoidoscopy/colonoscopy and biopsy
Radiology e.g. CT
What is the treatment for Crohn’s disease?
Steroids for acute attacks e.g. prednisolone, hydrocortisone
Additional therapy e.g. azathioprine, sulfasalazine, methotrexate, infliximab, adalimumab, certolixumab
Enteral nutrition e.g. modulen diet
Surgery - resection of obstructions or very diseased bowel
What complications can arise from Crohn’s disease?
Fissure in ano, haemorrhoids, skin tags, perianal abscesses, ischiorectal abscesses, fistula in ano, anorectal fistulae, increased risk of malignancy
What is the aetiology of ulcerative colitis?
Unknown, there is a link with HLA B27. Smoking is PROTECTIVE against ulcerative colitis.
What is the pathophysiology involved in ulcerative colitis?
There is continuous mucosal inflammation of the colon and rectum. Granulomas are rare and goblet cells are depleted in UC. Patients with UC have many crypt abscesses.
What are the symptoms of ulcerative colitis?
Diarrhoea +/- mucus or blood, tenesmus, abdominal pain/cramps, urgency, malaise, fever, anorexia, weight loss
What are the signs of ulcerative colitis?
Clubbing, tender abdomen, tachycardia, spondyloarthropathies
What tests are used to diagnose ulcerative colitis?
Sigmoidoscopy and biopsy
Abdo XR - colon dilatation, no faecal shadows and mucosal thickening
Stool - MC&S, faecal calprotectin, CDT
Bloods - FBC, U&Es, LFTs, CRP, ESR, folate, iron, albumin, serology e.g. ANCA (+ve)
CT
What is the treatment for ulcerative colitis?
Hydrocortisone in acute attacks with sulfasalazine and prednisolone to maintain remission
Additional therapy: infliximab, ciclosporin
Surgery: resection for perforation, massive haemorrhage, toxic dilatation or failure to respond to medical therapy
What complications can arise from ulcerative colitis?
Toxic megacolon, increased risk of developing malignancy
What is the aetiology of small intestine obstruction?
Adhesions, hernias, Crohn’s disease, intussusception, obstruction due to extrinsic involvement by cancer, meconium ileus, gallstone ileus
What is the pathophysiology involved in small intestine obstruction?
There is proximal dilatation of the intestine due to accumulation of GI secretions and air leading to mucosal wall oedema, ischaemia or perforation. There can also be fluid loss and electrolyte imbalance.
What are the symptoms of small intestine obstruction?
Colicky abdominal pain, vomiting (can be faeculent), abdominal distension, constipation, absence of passing wind
What are the signs of small intestine obstruction?
Increased bowel sounds, distended bowel - resonant on percussion, signs of dehydration and shock
What tests are used to diagnose small intestine obstruction?
History and examination
Abdo XR - distended loops of bowel, fluid levels
Non-contrast CT scan
Bloods: FBC, U&E, creatinine, group and save
What is the treatment for small intestine obstruction?
Uncomplicated obstruction - fluid resuscitation, electrolyte replacement, intestinal decompression and bowel rest. NG tube will reduce vomiting
Surgery - for ischaemia, perforation or peritonitis; a stoma may be required
What is the aetiology of a large bowel obstruction?
Colon cancer, sigmoid volvulus, diverticular disease, hernia, abscess, strictures, faecal impaction
What is the pathophysiology involved in a large bowel obstruction?
There is bowel dilatation above the obstruction leading to mucosal wall oedema and impaired venous and arterial blood flow to the bowel. There is increased mucosal permeability resulting in bacterial translocation, systemic toxicity, dehydration and electrolyte abnormalities.
What are the symptoms of a large bowel obstruction?
Abdominal pain, nausea and vomiting, constipation, fullness/bloating
What are the signs of a large bowel obstruction?
Tender abdomen, abdominal distension, quiet or absent bowel sounds, hyper-resonant on percussion
What tests are used to diagnose a large bowel obstruction?
History and examination Abdo XR - dilated bowel CT abdo Contrast radiography with enema Bloods - FBC, U&Es, creatinine, G&S, amylase
What is the treatment for a large bowel obstruction?
Uncomplicated obstruction - fluid resuscitation, electrolyte replacement, decompression and bowel rest
Surgery for ischaemia, perforation or peritonitis; stoma may be required
Endoscopic stenting of bowel is an option
Sigmoid volvulus - sigmoidoscopy can untwist the bowel j
What is the aetiology of ischaemic colitis?
Thrombosis, emboli, decreased cardiac output, shock, trauma, strangulated hernia or volvulus, drugs (e.g. oestrogens), surgery, vasculitis, coagulopathies
What is the pathophysiology of ischaemic colitis?
There is a compromise of the blood circulation supplying the colon, blood flow may be impaired by colonic distension leading to inflammation and injury
What are the symptoms of ischaemic colitis?
Acute onset abdominal pain, nausea and vomiting, loose stool, malaena
What are the signs of ischaemic colitis?
Absent bowel sounds, fever, abdominal tenderness, signs of shock such as tachycardia, confusion and hypotension
What tests are used to diagnose ischaemic colitis?
Colonoscopy
Abdominal XR - abnormal segment outlined with gas
ABG - metabolic acidosis (gives a clue)
Barium enema - thumb printing in the early phase
CT
Bloods - FBC (sometimes increased Hb and increased WCC), amylase (increased sometimes)
What is the treatment for ischaemic colitis?
Medical: ischaemia resolves once hypoperfusion is alleviated, bowel rest and supportive care, ?antibiotics
Surgery: resection of the ischaemic colon, a stoma may be required
What is the aetiology of haemorrhoids?
Constipation, prolonged straining and toilet time, increased abdominal pressure e.g. ascites, during pregnancy and childbirth, heavy lifting, chronic cough and aging are all risk factors
What is the pathophysiology involved in haemorrhoids?
Haemorrhoids are abnormally enlarged vascular mucosal cushions in the anal canal, normally they help maintain continence
What are the symptoms of haemorrhoids?
Bright red, painless rectal bleeding with defecation, anal itching and irritation, feeling of rectal fullness or discomfort
What tests are used to diagnose haemorrhoids?
A full history and examination including DRE
Flexi-sigmoidoscopy or colonoscopy to rule out malignancy
What is the treatment for haemorrhoids?
Depends on the degree of prolapse and the severity of symptoms
Prevention and management of constipation - increase fibre intake
Pain and symptom relief - analgesics, topical anaesthetics or topical corticosteroids
Procedures: rubber band ligation, infrared coagulation, injection sclerotherapy, bipolar diathermy
Surgery: haemorrhoidectomy, circular stapled haemorrhoidectomy, haemorrhoidal artery ligation
What are the risk factors for an anorectal abscess?
Patients with DM, immunocompromised patients, people who engage in receptive anal sex, patients with IBD
What is the pathophysiology involved in an anorectal abscess?
There is a collection of pus in the anal or rectal region, may be caused by an infection of an anal fissure, STI or blocked anal glands
What are the symptoms of an anorectal abscess?
Discharge of pus from the rectum, constipation, pain associated with bowel movements, perianal pain worse on sitting, fever
What are the signs of an anorectal abscess?
Hardened tissue in the perianal area, a lump or nodule in the perianal area
What tests are used to diagnose an anorectal abscess?
History and examination including DRE, possibly and STI screen or investigations for IBD
MRI useful in locating fistula tracts
USS can be helpful too
What is the treatment for an anorectal abscess?
Prompt surgical drainage, antibiotics if immunocompromised or DM, surgery
What complications can arise from an anorectal abscess?
Systemic infection, fissure in ano, recurrence, scarring
What is the aetiology for fistula in ano?
Approx 40% of anorectal abscesses progress to fistula in ano
They’re also associated with IBD, TB, diverticular disease, malignancy and actinomycosis
What is the pathophysiology of a fistula in ano?
There is an abnormal tract with the external opening in the perianal area which communicates with the anal canal
What are the symptoms of a fistula in ano?
Perianal discharge, pain, swelling, bleeding, itching, tenderness
What are the signs of a fistula in ano?
Skin maceration, fever, opening of the fistula may be seen, an area of thickening might be felt on DRE
What tests are used to diagnose a fistula in ano?
History and examination including DRE
Exploration of the fistula using a probe (can be done under anaesthesia)
Proctoscopy and/or sigmoidoscopy
What is the treatment for a fistula in ano?
Surgery to excise the fistula or open it and let it heal
Antibiotics if infection is present
What are the risk factors for a pilonidal sinus?
Risk factors include obesity, patients who sit for long periods e.g. lorry drivers, young males
What is the pathophysiology of a pilonidal sinus?
An abnormal pocket in the skin around the tailbone which fills with hair and skin debris, typically occurs after hair punctures the skin
What are the symptoms of a pilonidal sinus?
Pain/discomfort or swelling above the anus, purulent or bloody discharge, discomfort sitting on the tailbone/affected area
What are the signs of a pilonidal sinus?
Fever if an infection is present, sinus tract may be visible on examination, redness around the affected area.
What tests are used to diagnose a pilonidal sinus?
A full history and examination is all that is needed for making the diagnosis
What is the treatment for a pilonidal sinus?
Incision and drainage or excision may be required
Antibiotics may be required
What is the aetiology of IBS?
It is associated with increased levels of psychiatric distress and poor coping strategies. There is no structural lesion.
What is the pathophysiology of IBS?
Unknown as there is no structural lesion, though to be a combination of visceral hypersensitivity, altered gut microbiota, abnormal gut motility and autonomic nervous dysfunction
What are the symptoms of IBS?
Abdominal pain or discomfort, bloating, change in bowel habit, symptoms relieved by defecation, mucus in stool, symptoms worsened by eating, altered stool passage
What are the signs of IBS?
No specific physical signs
What tests are used to diagnose IBS?
Full history and examination
Bloods - FBC, U&Es, LFTs, CRP, ESR, coeliac serology, TSH
Stool - faecal calprotectin
Rome III criteria can help
What is the treatment for IBS?
Lifestyle modification: regular or small frequent meals, plenty of fluids, reduce caffeine, alcohol and fizzy drinks, increase soluble fibre intake
Possibly adopt a low FODMAP diet
Medication: antispasmodics e.g. buscopan, laxatives for constipation, anti-motility agents for diarrhoea, low dose tricyclic antidepressants
What are the risk factors for diverticular disease?
Increasing age, constipation, connective tissue disorders, genetic predisposition, extreme weight loss, heavy meat consumption and possibly a diet low in fibre (controversial)
What is the pathophysiology involved in diverticular disease?
There is herniation of mucosa and submucosa through the thickened colonic muscle resulting in small outpouchings in the colon
What are the symptoms of diverticular disease?
95% of cases are asymptomatic
Lower abdominal pain exacerbated by eating and diminished by defecation or flatus, bloating, constipation
What are the signs of diverticular disease?
Fullness or tenderness in the left lower quadrant, pyrexia or neutrophilia may indicate diverticulitis
What tests are used to diagnose diverticular disease?
Colonoscopy
Barium Enema
Bloods - FBC, U&Es, CRP, ESR, LFTs
What is the treatment for diverticular disease?
A high fibre diet and smooth muscle relaxants if required
What is a complication of diverticular disease?
Diverticulitis - inflammation of the diverticula
What are the symptoms of diverticulitis?
Left lower quadrant pain, nausea, vomiting
What are the signs of diverticulitis?
Pyrexia, tenderness of the site, signs of peritonitis if there’s perforation
What tests are used to diagnose diverticulitis?
Bloods (high WCC), CT, contrast enema
What is the treatment for diverticulitis?
Liquid diet and broad spectrum antibiotics, admit if very severe. May need surgical intervention
What is the aetiology of appendicitis?
A common cause is when the lumen of the appendix is obstructed by a faecolith, can also be generalised acute inflammation
What is the pathophysiology involved in appendicitis?
There is sudden inflammation in the appendix, gut flora invade the appendix causing infection and more inflammation, this can cause the appendix to rupture
What are the symptoms of appendicitis?
Pain - begins periumbilically and then moves to the right iliac fossa, nausea, vomiting, anorexia, constipation, diarrhoea
What are the signs of appendicitis?
Low grade pyrexia, localised tenderness, guarding and rebound tenderness in the right iliac fossa
Rovsing’s sign - pain > in RIF than LIF when LIF is pressed
What tests are used to diagnose appendicitis?
Appendicitis is a clinical diagnosis.
Urinalysis to rule out UTI
beta hCG to rule out ectopic pregnancy
Bloods - FBC, U&E, CRP (high) and ESR
USS or CT can help if unsure (can lead to delay in treatment however)
What is the treatment for appendicitis?
Surgery to resect appendix
IV fluids,
Opiate analgesia
Pre-operative antibiotics
What is the aetiology of acute pancreatitis?
Gallstones, alcohol, infections (e.g. mumps), tumours, drugs (e.g. azathioprine), iatrogenic (post-surgery, post-ECRP), hyperlipidaemias, trauma, idiopathic
What is the pathophysiology of acute pancreatitis?
A marked elevation of intracellular calcium activates proteases leading to cellular necrosis and periductal necrosis
What are the symptoms of acute pancreatitis?
Epigastric pain, nausea and vomiting, pain radiates to the back
What are the signs of acute pancreatitis?
Mild pyrexia, tachycardia, jaundice, abdominal tenderness with rigidity, bowel sounds are usually present in the early stages, pleural effusions, body wall staining around the umbilicus (Cullen’s sign) or flanks (Turner’s sign)
What tests are used to diagnose acute pancreatitis?
Bloods - FBC, U&Es, LFTs, serum amylase (>/= 3x normal is diagnostic), lipase levels Abdominal XR Contrast CT USS MRI
What is the treatment for acute pancreatitis?
Mild: manage on ward, pain relief, NBM, IV fluids, NG if vomiting is severe, give antibiotics for specific infections
Severe: manage in ITU, IV antibiotics if there’s significant necrosis, give enteral nutrition via NG, early ERCP for cholangitis or biliary obstruction, percutaneous drainage, surgical debridement
What complications can arise from acute pancreatitis?
Pancreatitis necrosis, infected necrosis, acute fluid collections, pancreatic abscess, acute pseudo-cyst, pancreatic ascites
What is the aetiology of chronic pancreatitis?
Alcohol, tropical, hereditary e.g. trypsinogen and inhibitory protein defects, cystic fibrosis, idiopathic, trauma, hypercalcaemia
What is the pathophysiology of chronic pancreatitis?
Inappropriate activation of enzymes in the pancreas leads to chronic inflammation and irreversible damage causing pancreatic tissue necrosis and fibrosis
What are the symptoms of chronic pancreatitis?
Severe epigastric pain radiating to the back, nausea and vomiting, decreased appetite, diarrhoea, steatorrhoea
What are the signs of chronic pancreatitis?
Malabsorption with weight loss, protein deficiency, jaundice, DM, tenderness in the abdomen
What tests are used to diagnose chronic pancreatitis?
Bloods - FBC, U&E, creatinine, LFTs, calcium, amylase, glucose, HbA1c
Stool - faecal elastase
Imaging - CT, USS, MRCP
What is the treatment for chronic pancreatitis?
Pain relief, ERCP, replace pancreatic enzymes in malabsorption, reduce alcohol intake, smoking cessation
What complications can arise from chronic pancreatitis?
DM, pancreatic malignancy
What is the aetiology of biliary colic?
It is frequently caused by obstruction of the common bile duct or the cystic duct by a gallstone
What is the pathophysiology involved in biliary colic?
Pain is caused due to a gallstone temporarily blocking a bile duct, it usually lasts a few hours
What are the symptoms of biliary colic?
Sharp right upper quadrant pain that radiates to the right shoulder, nausea and vomiting
What are the signs of biliary colic?
No specific physical signs, vital signs may be normal
What tests are used to diagnose biliary colic?
History and examination
Bloods - FBC, U&E, LFTs, CRP & ESR
USS of the liver and gallbladder
MRCP
What is the treatment for biliary colic?
Medical: anti-emetics and analgesia such as NSAIDs
Surgical: ERCP, cholecystectomy
What is the aetiology of cholecystitis?
Obstruction to the gallbladder, mostly caused by gallstones, can also be due to a tumour or scarring of the bile duct
What is the pathophysiology involved in cholecystitis?
Obstruction results in an increase of gallbladder glandular secretions leading to progressive distension which may compromise the vascular supply. There is also an inflammatory process secondary to retained bile.
What are the symptoms of cholecystitis?
Right upper quadrant pain or epigastric pain, becomes severe and constant, nausea and vomiting, pain can radiate to the right shoulder
What are the signs of cholecystitis?
Fever, abdominal tenderness, Murphy’s sign - pain with deep inspiration, mild jaundice
What tests are used to diagnose cholecystitis?
Bloods - FBC, U&Es, LFTs (increased bilirubin), CRP (high)
Imaging - USS, CT or MRCP
What is the treatment for cholecystitis?
NBM, IV fluids, IV antibiotics, opiate analgesia
Surgery - cholecystectomy
What complications can arise from cholecystitis?
Gangrene, gallbladder rupture, empyema, fistula formation, gallstone ileus
What are the risk factors for gallstones?
Five F’s
Increasing age, females, family history, multiparity, obesity +/- metabolic syndrome, rapid weight loss, DM, drugs e.g. oral contraceptive pill
What is the pathophysiology involved in gallstones?
Bile contains cholesterol, bile pigments and phospholipids, if the concentrations of these vary, different kinds of stones may be formed
What are the symptoms of gallstones?
Up to 70% of patients are asymptomatic
Epigastric or right upper quadrant pain radiating to the right shoulder, nausea and vomiting
What are the signs of gallstones?
Gallstones may cause obstructive jaundice, abdominal tenderness, fever, Murphy’s sign - pain on deep inspiration
What tests are used to diagnose gallstones?
Bloods - FBC, U&Es, LFTs, CRP
USS of the liver and gallbladder
CT
MRCP
What is the treatment for gallstones?
Analgesia, ERCP, cholecystectomy, percutaneous cholecystostomy for those unfit for GA, watch and wait if the stones are asymptomatic
What is the aetiology of viral hepatitis?
Cause by hepatitis viruses A - E
What are some risk factors for contracting hepatitis A?
Travel, eating shellfish and food handlers
What are some risk factors for contracting hepatitis B, C and D?
IVDUs, sex workers, healthcare workers
What are some risk factors for contracting hepatitis E?
Contaminated water, farm animals
What is the pathophysiology involved with viral hepatitis?
Infection with the virus causes inflammation in the liver causing hepatocytes to undergo degenerative changes such as swelling and necrosis
What are the symptoms of viral hepatitis?
Nausea and vomiting, myalgia, fatigue, malaise, headache, rhinitis, right upper quadrant pain
What are the signs of viral hepatitis?
Lymphadenopathy, jaundice, hepatomegaly, splenomegaly, spider naevia, clubbing leukonychia, gynaecomastia
What tests are used to diagnose viral hepatitis?
Bloods: serology and viral PCR
What is the treatment for viral hepatitis?
Hep A: self limiting, supportive
Hep B: supportive, antivirals e.g. pegylated interferon, tenofovir
Hep C: pegylated interferon and ribavirin
Hep D: pegylated interferon and adefovir
Hep E: Supportive, ribavirin if chornic
What are the complications of viral hepatitis?
Fulminant hepatitis - Hep A and E
Cirrhosis - Hep B, C and D
HCC - Hep B, C and D
Cholangiocarcinoma - Hep B and C
What is the aetiology of liver cirrhosis?
Alcohol, Hep B +/- D, Hep C, biliary cirrhosis, autoimmune hepatitis, Wilson’s disease, NAFLD, hereditary haemochromatosis
What is the pathophysiology involved in liver cirrhosis?
Cell necrosis leads to fibrosis and nodule formation
Cirrhosis can be micronodular (<3mm - ongoing alcohol damage or biliary tract disease) or macronodular
What are the symptoms of liver cirrhosis?
Right hypochondrial pain, haematemesis, malaena, fatigue, malaise, anorexia, nausea, weight loss, jaundice
What are the signs of liver cirrhosis?
Jaundice, pruritis, spider naevi, skin telangiectasia, palmar erythema, bruising, petechiae, ascites, oedema, hair loss, leukonychia, finger clubbing, Dupuytren’s contracture, hepatomegaly, splenomegaly
What tests are used to diagnose liver cirrhosis?
Bloods: FBC, LFTs, U&Es, CRP, ferritin, coagulation studies - high AST and ALT, gamma GT high in active alcoholics, hypoalbuminaemia, hyponatraemia, low PTT, low ferritin
Imaging: USS, CT or MRI, CXR possibly
Liver biopsy
What is the treatment for liver cirrhosis?
Treat the underlying cause Symptomatic treatment Lifestyle changes Monitor, especially for HCC Consider liver transplant
What is the aetiology of portal hypertension?
Prehepatic - portal vein thrombosis
Intrahepatic - Cirrhosis, primary biliary cirrhosis
Post-hepatic - IVC obstruction
What is the pathophysiology of portal hypertension?
Normal pressure in the portal vein is 5-10 mmHg, blockage increases this pressure (>10 mmHg) resulting in collateral circulation through porto-systemic shunts resulting in dilation of gastro-oesophageal veins leading to varices
What are the symptoms of portal hypertension?
Haematemesis, malaena, ascites, patients with portal hypertension are often asymptomatic
What are the signs of portal hypertension?
Dilated veins in the anterior abdominal wall, caput medusae, splenomegaly, ascites
What tests are used to diagnose portal hypertension?
Bloods: FBC, U&Es, LFTs, glucose, clotting screen
Imaging: abdominal USS and doppler, CT, MRI
OGD
What is the treatment for portal hypertension?
Treat the underlying cause, salt restriction and diuretics, beta blockers +/- nitrates
For bleeding varices: OGD and banding or injection sclerotherapy
TIPS - transjugular intrahepatic portosystemic shunt
Liver transplant
What is the aetiology of primary biliary cirrhosis?
Unknown, immunological mechanisms play a part as serum anti-mitochondrial antibodies are found in almost all patients
What is the pathophysiology of primary biliary cirrhosis?
There is progressive destruction of the bile ducts leading to cirrhosis. Cirrhosis is caused due to bile and other toxins building up in the liver.
Cholestasis leads to fibrosis leads to cirrhosis
What are the symptoms of primary biliary cirrhosis?
Pruritus
What are the signs of primary biliary cirrhosis?
Skin pigmentation, xanthelasma and xanthomas, hepatosplenomegaly, jaundice (occurs late, has a poor prognosis)
What tests are used to diagnose primary biliary cirrhosis?
Bloods: FBC, U&Es, LFTs, lipids, antibodies - high alk phos, high IgM, high cholesterol
USS - diffuse alteration of architecture
Biopsy - portal tract infiltrate of lymphocytes and plasma cells
What is the treatment for primary biliary cirrhosis?
Ursodeoxycholic acid, treat the itch usually with cholestyramine, treat the complications of cirrhosis, vitamin supplements, consider liver transplant
What is the aetiology of alcoholic liver disease?
Excessive consumption of alcohol over a long period of time resulting in ALD, Hep C infection accelerates the process of liver injury
What is the pathophysiology involved in alcoholic liver disease?
Metabolism of alcohol leads to a net increase in hepatic fatty acid and accumulation of fat. This is steatosis - fatty change. Too much fat leads to necrosis, inflammation. Mallory bodies and giant mitochondria present are indications of hepatitis and this can lead to cirrhosis.
What are the symptoms of ALD?
Nausea and vomiting, diarrhoea, anorexia, malaise
What are the signs of ALD?
Tachycardia, tachypnoea, febrile, organomegaly, peripheral oedema, ascites, jaundice, encephalopathy and coagulopathy.
What tests are used to diagnose ALD?
Bloods: LFTs - AST:ALT >2, high bilirubin, low albumin; FBC - high WCC, macrocytic anaemia; clotting, high PTT
USS liver +/- biopsy
Ascitic tap
What is the treatment for ALD?
Fatty liver: abstinence from alcohol, can use acamprosate, naltrexone
Hepatitis: abstinence, manage withdrawals (chlordiazepoxide), supplements (vitamin B/thiamine) and steroids
Cirrhosis: symptomatic treatment, lifestyle changes, monitor, consider liver transplant
What is the aetiology of haemochromatosis?
Defects in the HPE gene cause the majority of haemochromatosis; there are some other genetic associations
What is the pathophysiology involved in haemochromatosis?
There is a deficiency in the iron regulating hormone hepcidin which causes increased iron absorption leading to accumulation of iron in the tissues, especially the liver causing organ damage. Other organs affected are the pancreas, joints, heart, skin and gonads.
What are the symptoms of haemochromatosis?
Fatigue, weakness, arthropathy affecting various joints, non-specific abdominal problems, erectile dysfunction, heart problems
What are the signs of haemochromatosis?
Bronzing of the skin, hepatomegaly, amenorrhoea, hypogonadism, DM, arrhythmias, cardiomyopathy, neurological or psychiatric symptoms
What tests are used to diagnose haemochromatosis?
Bloods: FBC, ferritin (high), LFTs, hepatitis serology, genetic testing
Liver biopsy
MRI
What is the treatment for haemochromatosis?
Phlebotomy 400-500ml weekly or fortnightly, low iron diet, consider transplantation for hepatic decompensation
What is the aetiology of Wilson’s disease?
It is a genetic disease resulting in a molecular defect in a copper-transporting ATPase
What is the pathophysiology involved in Wilson’s disease?
There is decreased copper incorporation into caeruloplasmin, a glycoprotein synthesised in the liver, and decreased biliary copper excretion so copper accumulates in the liver.
What are the symptoms of Wilson’s disease?
Tremor, dysarthria, dysphagia, dyskinesias, dystonias, depression, personality changes, labile emotions, mania, reduced memory, reduced IQ
What are the signs of Wilson’s disease?
Parkinsonism, hepatitis, cirrhosis, fulminant liver failure, Kayser-Fleischer rings in the eyes, grey skin, hypermobility, blue lunulae, haemolysis, splenomegaly, ascites
What tests are used to diagnose Wilson’s disease?
24 hour urine collection - increased copper excretion
Bloods: LFTs (increased), serum caeruloplasmin (low)
Liver biopsy: hepatic copper concentration
Brain MRI
Genetic testing
What is the treatment for Wilson’s disease?
Avoid a copper rich diet
Medication: penicillamine (forms a soluble complex with copper), trientine, zinc supplementation (decreases absorption of copper)
Consider a liver transplant
What is the aetiology of alpha-1 anti-trypsin deficiency?
It is a genetic disease due to a mutation in the SERPINA 1 gene on chromosome 14
What is the pathophysiology in alpha-1 anti-trypsin deficiency?
Not all patients with A1AD will develop liver failure.
Liver failure is thought to occur as the protein is not secreted properly so it is accumulated in the liver.
Lung problems occur as it is a protease inhibitor so it inhibits neutrophil-protease degradation of elastin in the lungs. Without this, elastin is degraded unchecked.
What are the symptoms of alpha-1 anti-trypsin deficiency?
Dyspnoea, wheezing, rhonchi (coarse rattling), rales (crackles)
What are the signs of alpha-1 anti-trypsin deficiency?
Early onset emphysema in non-smokers, early onset jaundice and prolonged jaundice in neonates
What tests are used to diagnose alpha-1 anti-trypsin deficiency?
Liver biopsy - alpha-1 anti-trypsin stains with periodic acid schiff
Serum levels of alpha-1 anti-trypsin
CXR and lung function tests
What is the treatment for alpha-1 anti-trypsin deficiency?
Smoking cessation, treatment of symptoms, consider a liver or lung transplant
What is the aetiology of ascites?
Local inflammation e.g. peritonitis
Hypoalbuminaemia, portal hypertension, Budd-Chiari syndrome (occlusion of the hepatic vein)
What is the pathophysiology involved in ascites?
Can be transudate (portal hypertension) or exudates (inflammation or malignancy).
Can be up to 35L
What are the symptoms of ascites?
Progressive abdominal heaviness and pressure, dyspnoea
What are the signs of ascites?
Distended abdomen, stigmata of liver disease, dullness to percussion, shifting dullness, bulging at the flanks, fluid “thrill”, signs for an underlying cause e.g. portal hypertension
What tests are used to diagnose ascites?
USS of the liver and abdomen Ascitic tap (transudate - protein <30 g/L; exudate - protein >30 g/L) Bloods: FBC, U&Es, LFTs, coagulation
What is the treatment for ascites?
Restrict sodium Diuretics e.g. spironolactone Ascitic drainage Shunt/TIPS Treat underlying cause
What is the aetiology of peritonitis?
It can be bacterial, chemical (e.g. a bile leak post-op) or haematologic (ruptured ectopic pregnancy)
What is the pathophysiology involved in peritonitis?
The peritoneum becomes inflamed due to various causes. Poorly localised pain - visceral peritonitis; well localised pain - parietal peritonitis
What are the symptoms of peritonitis?
Severe abdominal pain (sudden onset indicates perforation, worse on coughing, moving
Pain may begin general before localising
What are the signs of peritonitis?
Abdominal guarding, tenderness, rigid abdomen, fever, tachycardia, signs of shock
What tests are used to diagnose peritonitis?
Clinical examination and history Bloods CXR and abdo XR CT scan of abdomen beta-hCG ECG
What is the treatment for peritonitis?
ABCDE
Treat the underlying cause e.g. appendicitis
Supportive care e.g. IV fluids, antibiotics
What is the aetiology of a volvulus?
Congenital intestinal malrotation, constipation, megacolon, excessively mobile colon
What is the pathophysiology of a volvulus?
In a sigmoid volvulus, a large sigmoid loop full of faeces and distended with gas twists on its mesenteric pedicle to create a closed-loop obstruction
What are the symptoms of a volvulus?
Sudden onset, colicky lower abdominal pain, constipation, vomiting, can present with vague abdominal discomfort
What are the signs of a volvulus?
Tympanitic, distended abdomen, possibly a palpable mass, possible signs of shock
What tests are used to diagnose a volvulus?
Abdo XR - single grossly dilated loop of bowel
Barium enema - can result in decompression
CT
Bloods
What is the treatment for a volvulus?
Decompression with a sigmoidoscope
Surgery - resection of the redundant sigmoid colon
What complications can arise from a volvulus?
Recurrence
Bowel obstruction
Perforation and faecal peritonitis
What is the aetiology of oesophageal cancer?
Smoking, alcohol excess, obesity, Barrett’s oesophagus, coeliac disease, breast cancer treated with radiotherapy
What is the pathophysiology of oesophageal cancer?
Adenocarcinoma arises from columnar epithelium in the lower oesophagus
SCC occurs in the upper 2/3 of the oesophagus
What are the symptoms of oesophageal cancer?
Dysphagia, weight loss, persistent heartburn, regurgitating food, chronic cough, haematemesis
What are the signs of oesophageal cancer?
Hoarse voice, malaena, anorexia, lymphadenopathy, aspiration pneumonia, SVC obstruction
What tests are used to diagnose oesophageal cancer?
OGD Barium swallow Bloods - FBC, U&Es, LFTs CT scan of the thorax and abdomen PET scan Tissue biopsy
What is the treatment for oesophageal cancer?
Surgery - oesophageaogastrectomy, stenting
Chemoradiation
Palliative therapy
Nutritional support e.g. PEG
What is the aetiology of gastric cancer?
H. pylori infection, smoking, dietary factors, genetic mutations and having a first degree relative with gastric cancer all increase risk
What is the pathophysiology of gastric cancer?
Intestinal type - well formed glandular structures, tumours are polypoid or ulcerating lesions
Diffuse type with poorly cohesive cells that tend to infiltrate the gastric wall
What are the symptoms of gastric cancer?
Epigastric pain (may be constant and severe), nausea, vomiting, weight loss
What are the signs of gastric cancer?
Weight loss, anaemia, palpable epigastric mass, abdominal tenderness, palpable lymph nodes
What tests are used to diagnose gastric cancer?
Bloods OGD Barium meal CT abdomen USS of the stomach and liver PET scan
What is the treatment for gastric cancer?
Gastrectomy
Chemoradio-therapy
Palliative care
What are the different types of gastric tumours?
Adenocarcinomas
Gastrointestinal stromal tumour
Primary gastric lymphoma
Gastric polyps - usually benign
What is the aetiology of small intestine tumours?
Coeliac disease, Crohn’s disease, immunoproliferative small intestinal disease
What are the different types of small intestine tumours?
Adenocarcinomas - rare
Lymphomas frequently found in the ileum
Carcinoid tumours - originate from the enterochromaffin cells
What is the clinical presentation of small intestine tumours?
Abdominal pain, diarrhoea, anorexia, weight loss, symptoms of anaemia
There may be a palpable mass and a small bowel follow through may detect a mass lesion
What tests are used to diagnose small intestine tumours?
Endoscopic biopsy is useful where lesions are within reach
USS and CT - bowel wall thickening and involvement of lymph nodes
Capsule endoscopy or double balloon endoscopy
What is the treatment for small intestine tumours?
Adenocarcinoma - segmental resection, chemotherapy and radiotherapy
IPSID - if no evidence of lymphoma, antibiotics e.g. tetracycline; if evidence of lymphoma, combination chemotherapy
Lymphoma - surgery, radiotherapy, chemotherapy
Carcinoid tumours - somatostatin analogues
What are some risk factors for developing colorectal cancer?
Smoking, diet (low fibre, high red meat, alcohol), previous adenoma, family history (FAP, HNPCC)
What is the pathophysiology involved in colorectal cancer?
Usually an adenocarcinoma
Usually a polypoid mass with ulceration, spreads by direct infiltration through the bowel wall
What are the symptoms of colorectal cancer?
PR bleeding, mucus, change of bowel habit - constipation and/or diarrhoea, absolute constipation, tenesmus, abdominal pain
What are the signs of colorectal cancer?
A rectal or abdominal mall may be palpable, iron deficiency anaemia, intestinal obstruction, hepatomegaly and liver mets
What tests are used to diagnose colorectal cancer?
Bloods - FBC, U&Es, LFTs, CEA (carcinoembryonic antigen)
Colonoscopy and biopsy
Double contrast barium enema
CT colonoscopy
What is the treatment for colorectal cancer?
Surgery - only chance of a cure, can be open, laparoscopic or robot
Non-surgical options - best supportive care, palliative chemotherapy
Rectal cancer is more difficult to excise due to the location
What is the aetiology of hernias?
Obesity, straining during a bowel movement or urination (constipation or BPH), hard coughing bouts (lung disease), ascites
What is the pathophysiology of a hernia?
An organ e.g. the bowel exits the cavity in which it normally resides through a weakness in the wall of the cavity
What are the symptoms of a hernia?
Pain at the site of the hernia, a visible or palpable lump, if scrotal then swelling in the scrotum
What are the signs of a hernia?
Swelling, an impulse (increase in swelling) on coughing
What tests are used to diagnose a hernia?
Full history and examination
CT of the abdomen andor chest/pelvis depending on location
USS
What is the treatment of a hernia?
Watch and wait
Surgery: replace contents of hernias into appropriate cavity and close wall defect
What is the aetiology of infective diarrhoea?
Rotavirus, Shigella, E. coli O157, Salmonella typhi, Salmonella paratyphi, hepatitis A, hepatitis E, Vibrio cholerae, norovirus, C. diff
What is the pathophysiology involved in infective diarrhoea?
Vomiting and diarrhoea are due to infection of the small or large bowel. Changes in the small bowel and typically non-inflammatory whilst ones in the large bowel are inflammatory.
What are the symptoms of infective diarrhoea?
Diarrhoea, vomiting, abdominal cramping, headache, fever, fatigue, muscle pain, bloody diarrhoea (indicates bacterial more likely)
What are the signs of infective diarrhoea?
Fever, signs of dehydration
What tests are used to diagnose infective diarrhoea?
Typically diagnosed based on history and examination
Stool culture
Bloods - FBC, U&Es, creatinine, serum glucose if worries about hypoglycaemia or dehydration
What is the treatment of infective diarrhoea?
Normally it is a self limiting illness - oral rehydration fluids or IV fluids, anti-emetics, anti-motility agents, antibiotics e.g. vancomycin PO for C. diff
