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Phase 2A > GI and Liver > Flashcards

GI and Liver Flashcards

1
Q

What is the aetiology of GORD?

A

Hiatus hernia, obesity, pregnancy, Zollinger-Ellison syndrome, hypercalcaemia, scleroderma and systemic sclerosis, smoking, drugs - antimuscarinics, CCB and nitrates

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2
Q

What is the pathophysiology involved in GORD?

A

Antireflux mechanisms fail, allowing gastric contents to make contact with the lower oesophageal mucosa. the sphincter relaxes independently of a swallow

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3
Q

What are the symptoms of GORD?

A

Heartburn aggravated by bending, stooping or lying down, regurgitation, nausea, chest pain and coughing

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4
Q

What are the signs of GORD?

A

Reflux pain that radiates to the arms, is relieved by antacids and is worse with hot drinks or alcohol

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5
Q

What tests are used to diagnose GORD?

A

OGD, barium meal, fully history and examination, 24-hour intraluminal monitoring

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6
Q

What is the treatment for GORD?

A

PPIs e.g. omeprazole, lansoprazole
Lifestyle measures e.g. smoking cessation, weight loss
Anti-reflux surgery

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7
Q

What complications can arise from GORD?

A

Peptic stricture

Barrett’s oesophagus

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8
Q

What is the aetiology of a Mallory-Weiss tear?

A

Increased abdominal pressure e.g. retching, vomiting, coughing, straining or even hiccuping.

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9
Q

What are some risk factors for a Mallory-Weiss tear?

A

Alcohol excess, gastroenteritis, bulimia, hepatitis

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10
Q

What is the pathophysiology involved in a Mallory-Weiss tear?

A

Increased abdominal pressure causes a linear mucosal tear resulting in bleeding, most bleeds are minor

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11
Q

What are the symptoms of a Mallory-Weiss tear?

A

Haematemesis following retching or vomiting, malaena, light-headedness, dizziness or syncope, abdominal pain, features associated with the cause of vomiting

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12
Q

What are the signs of a Mallory-Weiss tear?

A

No specific physical signs

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13
Q

What tests are used to diagnose a Mallory-Weiss tear?

A

OGD to visualise the tear
Bloods: FBC, coagulation studies and platelets, U&Es, renal function, cardiac enzymes (if MI suspected)
ECG (if MI suspected)

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14
Q

What is the treatment for a Mallory-Weiss tear?

A

ABCDE if the patient has lost a large volume of blood
Stop bleeding with endoscopic techniques.
Most patients stop bleeding spontaneously

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15
Q

What is the aetiology of a peptic ulcer?

A

H. pylori, NSAIDs, pepsin, smoking, alcohol, bile acids, steroids, stress, changes in gastric mucin consistency

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16
Q

What is the pathophysiology involved in a peptic ulcer?

A

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

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17
Q

What are the symptoms of a peptic ulcer?

A

Epigastric pain, nausea, burping, bloating, distension, heartburn, pain radiating to the back if the ulcer is posterior, symptoms relieved by antacids

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18
Q

What are the signs of a peptic ulcer?

A

Epigastric tenderness, anorexia and weight loss, succession splash if gastric emptying is slow

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19
Q

What tests are used for diagnosing a peptic ulcer?

A

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

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20
Q

What is the treatment of a peptic ulcer?

A

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

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21
Q

What are some possible complications of a peptic ulcer?

A

Haemorrhage, perforation, gastric outlet obstruction

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22
Q

What is the aetiology of gastro-oesophageal varices?

A

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

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23
Q

What is the pathophysiology involved in gastro-oesophageal varices?

A

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.

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24
Q

What are the symptoms of gastro-oesophageal varices?

A

Haematemesis, malaena, abdominal pain, features of liver disease and an underlying condition, dysphagia, confusion secondary to encephalopathy

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25
Q

What are the signs of gastro-oesophageal varices?

A

Peripherally shut down, pallor, hypotension, tachycardia, reduced urine output, malaena, signs of chronic liver disease, reduced GCS, signs of sepsis

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26
Q

What tests are used to diagnose gastro-oesophageal varices?

A 
Endoscopy 
CXR 
Ascitic tap if suspected SBP
Bloods: FBC, U&Es, LFTs, clotting screen, group and save, renal function, 
Investigate underlying cause
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27
Q

What is the treatment of gastro-oesophageal varices?

A

ABCDE if bleeding acutely and large volumes

Endoscopic band ligation, terlipressin, antibiotic prophylaxis

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28
Q

What is the aetiology of achalasia?

A

Unknown

Autoimmune, neurodegenerative and viral aetiologies have been implicated

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29
Q

What is the pathophysiology involved in achalasia?

A

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

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30
Q

What are the symptoms of achalasia?

A

Dysphagia, regurgitation, heartburn, chest pain - retrosternal

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31
Q

What are the signs of achalasia?

A

Rarely, there may be signs of aspiration pneumonia

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32
Q

What tests are used to diagnose achalasia?

A

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

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33
Q

What is the treatment for achalasia?

A

Heller myotomy, pneumatic dilatation of the oesophagus, endoscopic injection of botulinum toxin

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34
Q

What complications are associated with achalasia?

A

Aspiration pneumonia, GORD or perforation due to treatment, oesophageal cancer (SCC)

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35
Q

What is the aetiology of gastritis?

A

H. pylori infection, autoimmune causes, viruses e.g. CMV or HSV, duodenogastric reflux or Crohn’s disease

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36
Q

What is the pathophysiology of gastritis?

A

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.

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37
Q

What are the symptoms of gastritis?

A

Epigastric pain (can be dull, vague, burning, aching, gnawing, sore or sharp), nausea, vomiting, burping, bloating, early satiety, loss of appetite

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38
Q

What are the signs of gastritis?

A

No specific physical signs

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39
Q

What tests are used to diagnose gastritis?

A 
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
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40
Q

What is the treatment for gastritis?

A

H. pylori eradication - 2 antibiotics and a PPI
Antacids
PPIs (e.g. omeprazole)
H2 receptor antagonists (e.g. ranitidine)
Stop NSAID medications

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41
Q

What is the aetiology of coeliac disease?

A

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.

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42
Q

What is the pathophysiology of coeliac disease?

A

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.

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43
Q

What are the symptoms of coeliac disease?

A

Diarrhoea, steatorrhoea, abdominal discomfort, bloating or pain, weight loss, mouth ulcers

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44
Q

What are the signs of coeliac disease?

A

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

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45
Q

What tests are used to diagnose coeliac disease?

A

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

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46
Q

What is the treatment for coeliac disease?

A

Lifelong, strict, gluten free diet

Vitamin supplements if the patient is deficienct

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47
Q

What complications can arise from coeliac disease?

A

There is an increased risk of malignancy, intestinal lymphoma especially

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48
Q

What is the aetiology of Crohn’s disease?

A

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.

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49
Q

What is the pathophysiology involved in Crohn’s disease?

A

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.

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50
Q

What are the symptoms of Crohn’s disease?

A

Diarrhoea, abdominal pain, weight loss, fever, malaise, anorexia

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51
Q

What are the signs of Crohn’s disease?

A

Clubbing, mouth ulcers, erythema nodosum, pyoderma gangrenosum, iritis, conjunctivitis, episcleritis, large joint arthritis

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52
Q

What tests are used to diagnose Crohn’s disease?

A

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

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53
Q

What is the treatment for Crohn’s disease?

A

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

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54
Q

What complications can arise from Crohn’s disease?

A

Fissure in ano, haemorrhoids, skin tags, perianal abscesses, ischiorectal abscesses, fistula in ano, anorectal fistulae, increased risk of malignancy

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55
Q

What is the aetiology of ulcerative colitis?

A

Unknown, there is a link with HLA B27. Smoking is PROTECTIVE against ulcerative colitis.

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56
Q

What is the pathophysiology involved in ulcerative colitis?

A

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.

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57
Q

What are the symptoms of ulcerative colitis?

A

Diarrhoea +/- mucus or blood, tenesmus, abdominal pain/cramps, urgency, malaise, fever, anorexia, weight loss

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58
Q

What are the signs of ulcerative colitis?

A

Clubbing, tender abdomen, tachycardia, spondyloarthropathies

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59
Q

What tests are used to diagnose ulcerative colitis?

A

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

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60
Q

What is the treatment for ulcerative colitis?

A

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

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61
Q

What complications can arise from ulcerative colitis?

A

Toxic megacolon, increased risk of developing malignancy

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62
Q

What is the aetiology of small intestine obstruction?

A

Adhesions, hernias, Crohn’s disease, intussusception, obstruction due to extrinsic involvement by cancer, meconium ileus, gallstone ileus

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63
Q

What is the pathophysiology involved in small intestine obstruction?

A

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.

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64
Q

What are the symptoms of small intestine obstruction?

A

Colicky abdominal pain, vomiting (can be faeculent), abdominal distension, constipation, absence of passing wind

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65
Q

What are the signs of small intestine obstruction?

A

Increased bowel sounds, distended bowel - resonant on percussion, signs of dehydration and shock

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66
Q

What tests are used to diagnose small intestine obstruction?

A

History and examination
Abdo XR - distended loops of bowel, fluid levels
Non-contrast CT scan
Bloods: FBC, U&E, creatinine, group and save

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67
Q

What is the treatment for small intestine obstruction?

A

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

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68
Q

What is the aetiology of a large bowel obstruction?

A

Colon cancer, sigmoid volvulus, diverticular disease, hernia, abscess, strictures, faecal impaction

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69
Q

What is the pathophysiology involved in a large bowel obstruction?

A

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.

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70
Q

What are the symptoms of a large bowel obstruction?

A

Abdominal pain, nausea and vomiting, constipation, fullness/bloating

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71
Q

What are the signs of a large bowel obstruction?

A

Tender abdomen, abdominal distension, quiet or absent bowel sounds, hyper-resonant on percussion

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72
Q

What tests are used to diagnose a large bowel obstruction?

A 
History and examination
Abdo XR - dilated bowel 
CT abdo
Contrast radiography with enema
Bloods - FBC, U&Es, creatinine, G&S, amylase
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73
Q

What is the treatment for a large bowel obstruction?

A

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

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74
Q

What is the aetiology of ischaemic colitis?

A

Thrombosis, emboli, decreased cardiac output, shock, trauma, strangulated hernia or volvulus, drugs (e.g. oestrogens), surgery, vasculitis, coagulopathies

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75
Q

What is the pathophysiology of ischaemic colitis?

A

There is a compromise of the blood circulation supplying the colon, blood flow may be impaired by colonic distension leading to inflammation and injury

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76
Q

What are the symptoms of ischaemic colitis?

A

Acute onset abdominal pain, nausea and vomiting, loose stool, malaena

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77
Q

What are the signs of ischaemic colitis?

A

Absent bowel sounds, fever, abdominal tenderness, signs of shock such as tachycardia, confusion and hypotension

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78
Q

What tests are used to diagnose ischaemic colitis?

A

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)

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79
Q

What is the treatment for ischaemic colitis?

A

Medical: ischaemia resolves once hypoperfusion is alleviated, bowel rest and supportive care, ?antibiotics
Surgery: resection of the ischaemic colon, a stoma may be required

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80
Q

What is the aetiology of haemorrhoids?

A

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

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81
Q

What is the pathophysiology involved in haemorrhoids?

A

Haemorrhoids are abnormally enlarged vascular mucosal cushions in the anal canal, normally they help maintain continence

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82
Q

What are the symptoms of haemorrhoids?

A

Bright red, painless rectal bleeding with defecation, anal itching and irritation, feeling of rectal fullness or discomfort

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83
Q

What tests are used to diagnose haemorrhoids?

A

A full history and examination including DRE

Flexi-sigmoidoscopy or colonoscopy to rule out malignancy

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84
Q

What is the treatment for haemorrhoids?

A

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

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85
Q

What are the risk factors for an anorectal abscess?

A

Patients with DM, immunocompromised patients, people who engage in receptive anal sex, patients with IBD

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86
Q

What is the pathophysiology involved in an anorectal abscess?

A

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

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87
Q

What are the symptoms of an anorectal abscess?

A

Discharge of pus from the rectum, constipation, pain associated with bowel movements, perianal pain worse on sitting, fever

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88
Q

What are the signs of an anorectal abscess?

A

Hardened tissue in the perianal area, a lump or nodule in the perianal area

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89
Q

What tests are used to diagnose an anorectal abscess?

A

History and examination including DRE, possibly and STI screen or investigations for IBD
MRI useful in locating fistula tracts
USS can be helpful too

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90
Q

What is the treatment for an anorectal abscess?

A

Prompt surgical drainage, antibiotics if immunocompromised or DM, surgery

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91
Q

What complications can arise from an anorectal abscess?

A

Systemic infection, fissure in ano, recurrence, scarring

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92
Q

What is the aetiology for fistula in ano?

A

Approx 40% of anorectal abscesses progress to fistula in ano

They’re also associated with IBD, TB, diverticular disease, malignancy and actinomycosis

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93
Q

What is the pathophysiology of a fistula in ano?

A

There is an abnormal tract with the external opening in the perianal area which communicates with the anal canal

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94
Q

What are the symptoms of a fistula in ano?

A

Perianal discharge, pain, swelling, bleeding, itching, tenderness

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95
Q

What are the signs of a fistula in ano?

A

Skin maceration, fever, opening of the fistula may be seen, an area of thickening might be felt on DRE

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96
Q

What tests are used to diagnose a fistula in ano?

A

History and examination including DRE
Exploration of the fistula using a probe (can be done under anaesthesia)
Proctoscopy and/or sigmoidoscopy

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97
Q

What is the treatment for a fistula in ano?

A

Surgery to excise the fistula or open it and let it heal

Antibiotics if infection is present

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98
Q

What are the risk factors for a pilonidal sinus?

A

Risk factors include obesity, patients who sit for long periods e.g. lorry drivers, young males

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99
Q

What is the pathophysiology of a pilonidal sinus?

A

An abnormal pocket in the skin around the tailbone which fills with hair and skin debris, typically occurs after hair punctures the skin

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100
Q

What are the symptoms of a pilonidal sinus?

A

Pain/discomfort or swelling above the anus, purulent or bloody discharge, discomfort sitting on the tailbone/affected area

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101
Q

What are the signs of a pilonidal sinus?

A

Fever if an infection is present, sinus tract may be visible on examination, redness around the affected area.

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102
Q

What tests are used to diagnose a pilonidal sinus?

A

A full history and examination is all that is needed for making the diagnosis

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103
Q

What is the treatment for a pilonidal sinus?

A

Incision and drainage or excision may be required

Antibiotics may be required

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104
Q

What is the aetiology of IBS?

A

It is associated with increased levels of psychiatric distress and poor coping strategies. There is no structural lesion.

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105
Q

What is the pathophysiology of IBS?

A

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

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106
Q

What are the symptoms of IBS?

A

Abdominal pain or discomfort, bloating, change in bowel habit, symptoms relieved by defecation, mucus in stool, symptoms worsened by eating, altered stool passage

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107
Q

What are the signs of IBS?

A

No specific physical signs

108
Q

What tests are used to diagnose IBS?

A

Full history and examination
Bloods - FBC, U&Es, LFTs, CRP, ESR, coeliac serology, TSH
Stool - faecal calprotectin
Rome III criteria can help

109
Q

What is the treatment for IBS?

A

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

110
Q

What are the risk factors for diverticular disease?

A

Increasing age, constipation, connective tissue disorders, genetic predisposition, extreme weight loss, heavy meat consumption and possibly a diet low in fibre (controversial)

111
Q

What is the pathophysiology involved in diverticular disease?

A

There is herniation of mucosa and submucosa through the thickened colonic muscle resulting in small outpouchings in the colon

112
Q

What are the symptoms of diverticular disease?

A

95% of cases are asymptomatic

Lower abdominal pain exacerbated by eating and diminished by defecation or flatus, bloating, constipation

113
Q

What are the signs of diverticular disease?

A

Fullness or tenderness in the left lower quadrant, pyrexia or neutrophilia may indicate diverticulitis

114
Q

What tests are used to diagnose diverticular disease?

A

Colonoscopy
Barium Enema
Bloods - FBC, U&Es, CRP, ESR, LFTs

115
Q

What is the treatment for diverticular disease?

A

A high fibre diet and smooth muscle relaxants if required

116
Q

What is a complication of diverticular disease?

A

Diverticulitis - inflammation of the diverticula

117
Q

What are the symptoms of diverticulitis?

A

Left lower quadrant pain, nausea, vomiting

118
Q

What are the signs of diverticulitis?

A

Pyrexia, tenderness of the site, signs of peritonitis if there’s perforation

119
Q

What tests are used to diagnose diverticulitis?

A

Bloods (high WCC), CT, contrast enema

120
Q

What is the treatment for diverticulitis?

A

Liquid diet and broad spectrum antibiotics, admit if very severe. May need surgical intervention

121
Q

What is the aetiology of appendicitis?

A

A common cause is when the lumen of the appendix is obstructed by a faecolith, can also be generalised acute inflammation

122
Q

What is the pathophysiology involved in appendicitis?

A

There is sudden inflammation in the appendix, gut flora invade the appendix causing infection and more inflammation, this can cause the appendix to rupture

123
Q

What are the symptoms of appendicitis?

A

Pain - begins periumbilically and then moves to the right iliac fossa, nausea, vomiting, anorexia, constipation, diarrhoea

124
Q

What are the signs of appendicitis?

A

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

125
Q

What tests are used to diagnose appendicitis?

A

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)

126
Q

What is the treatment for appendicitis?

A

Surgery to resect appendix
IV fluids,
Opiate analgesia
Pre-operative antibiotics

127
Q

What is the aetiology of acute pancreatitis?

A

Gallstones, alcohol, infections (e.g. mumps), tumours, drugs (e.g. azathioprine), iatrogenic (post-surgery, post-ECRP), hyperlipidaemias, trauma, idiopathic

128
Q

What is the pathophysiology of acute pancreatitis?

A

A marked elevation of intracellular calcium activates proteases leading to cellular necrosis and periductal necrosis

129
Q

What are the symptoms of acute pancreatitis?

A

Epigastric pain, nausea and vomiting, pain radiates to the back

130
Q

What are the signs of acute pancreatitis?

A

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)

131
Q

What tests are used to diagnose acute pancreatitis?

A 
Bloods - FBC, U&Es, LFTs, serum amylase (>/= 3x normal is diagnostic), lipase levels
Abdominal XR
Contrast CT
USS 
MRI
132
Q

What is the treatment for acute pancreatitis?

A

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

133
Q

What complications can arise from acute pancreatitis?

A

Pancreatitis necrosis, infected necrosis, acute fluid collections, pancreatic abscess, acute pseudo-cyst, pancreatic ascites

134
Q

What is the aetiology of chronic pancreatitis?

A

Alcohol, tropical, hereditary e.g. trypsinogen and inhibitory protein defects, cystic fibrosis, idiopathic, trauma, hypercalcaemia

135
Q

What is the pathophysiology of chronic pancreatitis?

A

Inappropriate activation of enzymes in the pancreas leads to chronic inflammation and irreversible damage causing pancreatic tissue necrosis and fibrosis

136
Q

What are the symptoms of chronic pancreatitis?

A

Severe epigastric pain radiating to the back, nausea and vomiting, decreased appetite, diarrhoea, steatorrhoea

137
Q

What are the signs of chronic pancreatitis?

A

Malabsorption with weight loss, protein deficiency, jaundice, DM, tenderness in the abdomen

138
Q

What tests are used to diagnose chronic pancreatitis?

A

Bloods - FBC, U&E, creatinine, LFTs, calcium, amylase, glucose, HbA1c
Stool - faecal elastase
Imaging - CT, USS, MRCP

139
Q

What is the treatment for chronic pancreatitis?

A

Pain relief, ERCP, replace pancreatic enzymes in malabsorption, reduce alcohol intake, smoking cessation

140
Q

What complications can arise from chronic pancreatitis?

A

DM, pancreatic malignancy

141
Q

What is the aetiology of biliary colic?

A

It is frequently caused by obstruction of the common bile duct or the cystic duct by a gallstone

142
Q

What is the pathophysiology involved in biliary colic?

A

Pain is caused due to a gallstone temporarily blocking a bile duct, it usually lasts a few hours

143
Q

What are the symptoms of biliary colic?

A

Sharp right upper quadrant pain that radiates to the right shoulder, nausea and vomiting

144
Q

What are the signs of biliary colic?

A

No specific physical signs, vital signs may be normal

145
Q

What tests are used to diagnose biliary colic?

A

History and examination
Bloods - FBC, U&E, LFTs, CRP & ESR
USS of the liver and gallbladder
MRCP

146
Q

What is the treatment for biliary colic?

A

Medical: anti-emetics and analgesia such as NSAIDs
Surgical: ERCP, cholecystectomy

147
Q

What is the aetiology of cholecystitis?

A

Obstruction to the gallbladder, mostly caused by gallstones, can also be due to a tumour or scarring of the bile duct

148
Q

What is the pathophysiology involved in cholecystitis?

A

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.

149
Q

What are the symptoms of cholecystitis?

A

Right upper quadrant pain or epigastric pain, becomes severe and constant, nausea and vomiting, pain can radiate to the right shoulder

150
Q

What are the signs of cholecystitis?

A

Fever, abdominal tenderness, Murphy’s sign - pain with deep inspiration, mild jaundice

151
Q

What tests are used to diagnose cholecystitis?

A

Bloods - FBC, U&Es, LFTs (increased bilirubin), CRP (high)
Imaging - USS, CT or MRCP

152
Q

What is the treatment for cholecystitis?

A

NBM, IV fluids, IV antibiotics, opiate analgesia

Surgery - cholecystectomy

153
Q

What complications can arise from cholecystitis?

A

Gangrene, gallbladder rupture, empyema, fistula formation, gallstone ileus

154
Q

What are the risk factors for gallstones?

A

Five F’s
Increasing age, females, family history, multiparity, obesity +/- metabolic syndrome, rapid weight loss, DM, drugs e.g. oral contraceptive pill

155
Q

What is the pathophysiology involved in gallstones?

A

Bile contains cholesterol, bile pigments and phospholipids, if the concentrations of these vary, different kinds of stones may be formed

156
Q

What are the symptoms of gallstones?

A

Up to 70% of patients are asymptomatic

Epigastric or right upper quadrant pain radiating to the right shoulder, nausea and vomiting

157
Q

What are the signs of gallstones?

A

Gallstones may cause obstructive jaundice, abdominal tenderness, fever, Murphy’s sign - pain on deep inspiration

158
Q

What tests are used to diagnose gallstones?

A

Bloods - FBC, U&Es, LFTs, CRP
USS of the liver and gallbladder
CT
MRCP

159
Q

What is the treatment for gallstones?

A

Analgesia, ERCP, cholecystectomy, percutaneous cholecystostomy for those unfit for GA, watch and wait if the stones are asymptomatic

160
Q

What is the aetiology of viral hepatitis?

A

Cause by hepatitis viruses A - E

161
Q

What are some risk factors for contracting hepatitis A?

A

Travel, eating shellfish and food handlers

162
Q

What are some risk factors for contracting hepatitis B, C and D?

A

IVDUs, sex workers, healthcare workers

163
Q

What are some risk factors for contracting hepatitis E?

A

Contaminated water, farm animals

164
Q

What is the pathophysiology involved with viral hepatitis?

A

Infection with the virus causes inflammation in the liver causing hepatocytes to undergo degenerative changes such as swelling and necrosis

165
Q

What are the symptoms of viral hepatitis?

A

Nausea and vomiting, myalgia, fatigue, malaise, headache, rhinitis, right upper quadrant pain

166
Q

What are the signs of viral hepatitis?

A

Lymphadenopathy, jaundice, hepatomegaly, splenomegaly, spider naevia, clubbing leukonychia, gynaecomastia

167
Q

What tests are used to diagnose viral hepatitis?

A

Bloods: serology and viral PCR

168
Q

What is the treatment for viral hepatitis?

A

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

169
Q

What are the complications of viral hepatitis?

A

Fulminant hepatitis - Hep A and E
Cirrhosis - Hep B, C and D
HCC - Hep B, C and D
Cholangiocarcinoma - Hep B and C

170
Q

What is the aetiology of liver cirrhosis?

A

Alcohol, Hep B +/- D, Hep C, biliary cirrhosis, autoimmune hepatitis, Wilson’s disease, NAFLD, hereditary haemochromatosis

171
Q

What is the pathophysiology involved in liver cirrhosis?

A

Cell necrosis leads to fibrosis and nodule formation

Cirrhosis can be micronodular (<3mm - ongoing alcohol damage or biliary tract disease) or macronodular

172
Q

What are the symptoms of liver cirrhosis?

A

Right hypochondrial pain, haematemesis, malaena, fatigue, malaise, anorexia, nausea, weight loss, jaundice

173
Q

What are the signs of liver cirrhosis?

A

Jaundice, pruritis, spider naevi, skin telangiectasia, palmar erythema, bruising, petechiae, ascites, oedema, hair loss, leukonychia, finger clubbing, Dupuytren’s contracture, hepatomegaly, splenomegaly

174
Q

What tests are used to diagnose liver cirrhosis?

A

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

175
Q

What is the treatment for liver cirrhosis?

A 
Treat the underlying cause 
Symptomatic treatment 
Lifestyle changes 
Monitor, especially for HCC
Consider liver transplant
176
Q

What is the aetiology of portal hypertension?

A

Prehepatic - portal vein thrombosis
Intrahepatic - Cirrhosis, primary biliary cirrhosis
Post-hepatic - IVC obstruction

177
Q

What is the pathophysiology of portal hypertension?

A

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

178
Q

What are the symptoms of portal hypertension?

A

Haematemesis, malaena, ascites, patients with portal hypertension are often asymptomatic

179
Q

What are the signs of portal hypertension?

A

Dilated veins in the anterior abdominal wall, caput medusae, splenomegaly, ascites

180
Q

What tests are used to diagnose portal hypertension?

A

Bloods: FBC, U&Es, LFTs, glucose, clotting screen
Imaging: abdominal USS and doppler, CT, MRI
OGD

181
Q

What is the treatment for portal hypertension?

A

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

182
Q

What is the aetiology of primary biliary cirrhosis?

A

Unknown, immunological mechanisms play a part as serum anti-mitochondrial antibodies are found in almost all patients

183
Q

What is the pathophysiology of primary biliary cirrhosis?

A

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

184
Q

What are the symptoms of primary biliary cirrhosis?

A

Pruritus

185
Q

What are the signs of primary biliary cirrhosis?

A

Skin pigmentation, xanthelasma and xanthomas, hepatosplenomegaly, jaundice (occurs late, has a poor prognosis)

186
Q

What tests are used to diagnose primary biliary cirrhosis?

A

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

187
Q

What is the treatment for primary biliary cirrhosis?

A

Ursodeoxycholic acid, treat the itch usually with cholestyramine, treat the complications of cirrhosis, vitamin supplements, consider liver transplant

188
Q

What is the aetiology of alcoholic liver disease?

A

Excessive consumption of alcohol over a long period of time resulting in ALD, Hep C infection accelerates the process of liver injury

189
Q

What is the pathophysiology involved in alcoholic liver disease?

A

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.

190
Q

What are the symptoms of ALD?

A

Nausea and vomiting, diarrhoea, anorexia, malaise

191
Q

What are the signs of ALD?

A

Tachycardia, tachypnoea, febrile, organomegaly, peripheral oedema, ascites, jaundice, encephalopathy and coagulopathy.

192
Q

What tests are used to diagnose ALD?

A

Bloods: LFTs - AST:ALT >2, high bilirubin, low albumin; FBC - high WCC, macrocytic anaemia; clotting, high PTT
USS liver +/- biopsy
Ascitic tap

193
Q

What is the treatment for ALD?

A

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

194
Q

What is the aetiology of haemochromatosis?

A

Defects in the HPE gene cause the majority of haemochromatosis; there are some other genetic associations

195
Q

What is the pathophysiology involved in haemochromatosis?

A

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.

196
Q

What are the symptoms of haemochromatosis?

A

Fatigue, weakness, arthropathy affecting various joints, non-specific abdominal problems, erectile dysfunction, heart problems

197
Q

What are the signs of haemochromatosis?

A

Bronzing of the skin, hepatomegaly, amenorrhoea, hypogonadism, DM, arrhythmias, cardiomyopathy, neurological or psychiatric symptoms

198
Q

What tests are used to diagnose haemochromatosis?

A

Bloods: FBC, ferritin (high), LFTs, hepatitis serology, genetic testing
Liver biopsy
MRI

199
Q

What is the treatment for haemochromatosis?

A

Phlebotomy 400-500ml weekly or fortnightly, low iron diet, consider transplantation for hepatic decompensation

200
Q

What is the aetiology of Wilson’s disease?

A

It is a genetic disease resulting in a molecular defect in a copper-transporting ATPase

201
Q

What is the pathophysiology involved in Wilson’s disease?

A

There is decreased copper incorporation into caeruloplasmin, a glycoprotein synthesised in the liver, and decreased biliary copper excretion so copper accumulates in the liver.

202
Q

What are the symptoms of Wilson’s disease?

A

Tremor, dysarthria, dysphagia, dyskinesias, dystonias, depression, personality changes, labile emotions, mania, reduced memory, reduced IQ

203
Q

What are the signs of Wilson’s disease?

A

Parkinsonism, hepatitis, cirrhosis, fulminant liver failure, Kayser-Fleischer rings in the eyes, grey skin, hypermobility, blue lunulae, haemolysis, splenomegaly, ascites

204
Q

What tests are used to diagnose Wilson’s disease?

A

24 hour urine collection - increased copper excretion
Bloods: LFTs (increased), serum caeruloplasmin (low)
Liver biopsy: hepatic copper concentration
Brain MRI
Genetic testing

205
Q

What is the treatment for Wilson’s disease?

A

Avoid a copper rich diet
Medication: penicillamine (forms a soluble complex with copper), trientine, zinc supplementation (decreases absorption of copper)
Consider a liver transplant

206
Q

What is the aetiology of alpha-1 anti-trypsin deficiency?

A

It is a genetic disease due to a mutation in the SERPINA 1 gene on chromosome 14

207
Q

What is the pathophysiology in alpha-1 anti-trypsin deficiency?

A

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.

208
Q

What are the symptoms of alpha-1 anti-trypsin deficiency?

A

Dyspnoea, wheezing, rhonchi (coarse rattling), rales (crackles)

209
Q

What are the signs of alpha-1 anti-trypsin deficiency?

A

Early onset emphysema in non-smokers, early onset jaundice and prolonged jaundice in neonates

210
Q

What tests are used to diagnose alpha-1 anti-trypsin deficiency?

A

Liver biopsy - alpha-1 anti-trypsin stains with periodic acid schiff
Serum levels of alpha-1 anti-trypsin
CXR and lung function tests

211
Q

What is the treatment for alpha-1 anti-trypsin deficiency?

A

Smoking cessation, treatment of symptoms, consider a liver or lung transplant

212
Q

What is the aetiology of ascites?

A

Local inflammation e.g. peritonitis

Hypoalbuminaemia, portal hypertension, Budd-Chiari syndrome (occlusion of the hepatic vein)

213
Q

What is the pathophysiology involved in ascites?

A

Can be transudate (portal hypertension) or exudates (inflammation or malignancy).
Can be up to 35L

214
Q

What are the symptoms of ascites?

A

Progressive abdominal heaviness and pressure, dyspnoea

215
Q

What are the signs of ascites?

A

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

216
Q

What tests are used to diagnose ascites?

A 
USS of the liver and abdomen
Ascitic tap (transudate - protein <30 g/L; exudate - protein >30 g/L) 
Bloods: FBC, U&amp;Es, LFTs, coagulation
217
Q

What is the treatment for ascites?

A 
Restrict sodium
Diuretics e.g. spironolactone
Ascitic drainage 
Shunt/TIPS
Treat underlying cause
218
Q

What is the aetiology of peritonitis?

A

It can be bacterial, chemical (e.g. a bile leak post-op) or haematologic (ruptured ectopic pregnancy)

219
Q

What is the pathophysiology involved in peritonitis?

A

The peritoneum becomes inflamed due to various causes. Poorly localised pain - visceral peritonitis; well localised pain - parietal peritonitis

220
Q

What are the symptoms of peritonitis?

A

Severe abdominal pain (sudden onset indicates perforation, worse on coughing, moving
Pain may begin general before localising

221
Q

What are the signs of peritonitis?

A

Abdominal guarding, tenderness, rigid abdomen, fever, tachycardia, signs of shock

222
Q

What tests are used to diagnose peritonitis?

A 
Clinical examination and history
Bloods
CXR and abdo XR
CT scan of abdomen
beta-hCG
ECG
223
Q

What is the treatment for peritonitis?

A

ABCDE
Treat the underlying cause e.g. appendicitis
Supportive care e.g. IV fluids, antibiotics

224
Q

What is the aetiology of a volvulus?

A

Congenital intestinal malrotation, constipation, megacolon, excessively mobile colon

225
Q

What is the pathophysiology of a volvulus?

A

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

226
Q

What are the symptoms of a volvulus?

A

Sudden onset, colicky lower abdominal pain, constipation, vomiting, can present with vague abdominal discomfort

227
Q

What are the signs of a volvulus?

A

Tympanitic, distended abdomen, possibly a palpable mass, possible signs of shock

228
Q

What tests are used to diagnose a volvulus?

A

Abdo XR - single grossly dilated loop of bowel
Barium enema - can result in decompression
CT
Bloods

229
Q

What is the treatment for a volvulus?

A

Decompression with a sigmoidoscope

Surgery - resection of the redundant sigmoid colon

230
Q

What complications can arise from a volvulus?

A

Recurrence
Bowel obstruction
Perforation and faecal peritonitis

231
Q

What is the aetiology of oesophageal cancer?

A

Smoking, alcohol excess, obesity, Barrett’s oesophagus, coeliac disease, breast cancer treated with radiotherapy

232
Q

What is the pathophysiology of oesophageal cancer?

A

Adenocarcinoma arises from columnar epithelium in the lower oesophagus
SCC occurs in the upper 2/3 of the oesophagus

233
Q

What are the symptoms of oesophageal cancer?

A

Dysphagia, weight loss, persistent heartburn, regurgitating food, chronic cough, haematemesis

234
Q

What are the signs of oesophageal cancer?

A

Hoarse voice, malaena, anorexia, lymphadenopathy, aspiration pneumonia, SVC obstruction

235
Q

What tests are used to diagnose oesophageal cancer?

A 
OGD
Barium swallow
Bloods - FBC, U&amp;Es, LFTs
CT scan of the thorax and abdomen
PET scan
Tissue biopsy
236
Q

What is the treatment for oesophageal cancer?

A

Surgery - oesophageaogastrectomy, stenting
Chemoradiation
Palliative therapy
Nutritional support e.g. PEG

237
Q

What is the aetiology of gastric cancer?

A

H. pylori infection, smoking, dietary factors, genetic mutations and having a first degree relative with gastric cancer all increase risk

238
Q

What is the pathophysiology of gastric cancer?

A

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

239
Q

What are the symptoms of gastric cancer?

A

Epigastric pain (may be constant and severe), nausea, vomiting, weight loss

240
Q

What are the signs of gastric cancer?

A

Weight loss, anaemia, palpable epigastric mass, abdominal tenderness, palpable lymph nodes

241
Q

What tests are used to diagnose gastric cancer?

A 
Bloods
OGD
Barium meal 
CT abdomen
USS of the stomach and liver 
PET scan
242
Q

What is the treatment for gastric cancer?

A

Gastrectomy
Chemoradio-therapy
Palliative care

243
Q

What are the different types of gastric tumours?

A

Adenocarcinomas
Gastrointestinal stromal tumour
Primary gastric lymphoma
Gastric polyps - usually benign

244
Q

What is the aetiology of small intestine tumours?

A

Coeliac disease, Crohn’s disease, immunoproliferative small intestinal disease

245
Q

What are the different types of small intestine tumours?

A

Adenocarcinomas - rare
Lymphomas frequently found in the ileum
Carcinoid tumours - originate from the enterochromaffin cells

246
Q

What is the clinical presentation of small intestine tumours?

A

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

247
Q

What tests are used to diagnose small intestine tumours?

A

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

248
Q

What is the treatment for small intestine tumours?

A

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

249
Q

What are some risk factors for developing colorectal cancer?

A

Smoking, diet (low fibre, high red meat, alcohol), previous adenoma, family history (FAP, HNPCC)

250
Q

What is the pathophysiology involved in colorectal cancer?

A

Usually an adenocarcinoma

Usually a polypoid mass with ulceration, spreads by direct infiltration through the bowel wall

251
Q

What are the symptoms of colorectal cancer?

A

PR bleeding, mucus, change of bowel habit - constipation and/or diarrhoea, absolute constipation, tenesmus, abdominal pain

252
Q

What are the signs of colorectal cancer?

A

A rectal or abdominal mall may be palpable, iron deficiency anaemia, intestinal obstruction, hepatomegaly and liver mets

253
Q

What tests are used to diagnose colorectal cancer?

A

Bloods - FBC, U&Es, LFTs, CEA (carcinoembryonic antigen)
Colonoscopy and biopsy
Double contrast barium enema
CT colonoscopy

254
Q

What is the treatment for colorectal cancer?

A

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

255
Q

What is the aetiology of hernias?

A

Obesity, straining during a bowel movement or urination (constipation or BPH), hard coughing bouts (lung disease), ascites

256
Q

What is the pathophysiology of a hernia?

A

An organ e.g. the bowel exits the cavity in which it normally resides through a weakness in the wall of the cavity

257
Q

What are the symptoms of a hernia?

A

Pain at the site of the hernia, a visible or palpable lump, if scrotal then swelling in the scrotum

258
Q

What are the signs of a hernia?

A

Swelling, an impulse (increase in swelling) on coughing

259
Q

What tests are used to diagnose a hernia?

A

Full history and examination
CT of the abdomen andor chest/pelvis depending on location
USS

260
Q

What is the treatment of a hernia?

A

Watch and wait

Surgery: replace contents of hernias into appropriate cavity and close wall defect

261
Q

What is the aetiology of infective diarrhoea?

A

Rotavirus, Shigella, E. coli O157, Salmonella typhi, Salmonella paratyphi, hepatitis A, hepatitis E, Vibrio cholerae, norovirus, C. diff

262
Q

What is the pathophysiology involved in infective diarrhoea?

A

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.

263
Q

What are the symptoms of infective diarrhoea?

A

Diarrhoea, vomiting, abdominal cramping, headache, fever, fatigue, muscle pain, bloody diarrhoea (indicates bacterial more likely)

264
Q

What are the signs of infective diarrhoea?

A

Fever, signs of dehydration

265
Q

What tests are used to diagnose infective diarrhoea?

A

Typically diagnosed based on history and examination
Stool culture
Bloods - FBC, U&Es, creatinine, serum glucose if worries about hypoglycaemia or dehydration

266
Q

What is the treatment of infective diarrhoea?

A

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

Phase 2A (11 decks)

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