GI Clinical Flashcards
1
Q
What are common symptoms of functional disorders?
A
Nausea
Vomiting
Diarrhoea
Constipation
2
Q
What is Stomatitis
A
Inflammation in the mouth due to any cause
3
Q
What is angular stomatitis?
A
Type of inflammation in the mouth but it occurs in the corners.
4
Q
What is Halitosis?
A
Bad Breath
5
Q
What are the causes of Halitosis?
A
- Poor oral hygiene
- Anxiety
- Oseophageal stricture
- Pulmonary sepsis
6
Q
What are the causes of Indigestion?
A
Constipation
or blockage in the stool
7
Q
Red flags which are related to dyspepsia which suggest cancer?
ii. What age group have a higher risk of significant GI pathology related to this?
A
- Dysphagia
- Weight loss
- Vomiting
- Anorexia
- Haemetesis
- Melena.
ii. 55 and above
8
Q
What is the difference between Nausea an Retching?
A
Nausea is the feeling of wanting to vomit
Retching- Strong involuntary but unproductive attempt to vomit.
9
Q
Give examples of causes for vomiting.
A
- Any GI disease
- Infections: Viral- influenza or norovirus
Bacteria: Pertussis or Urinary infection - CNS disease: Raise intracranial pressure, vesitibular disturbance or migraine.
- Metabolic : Uraemia or Hypercalcaemia
10
Q
What does faeculent vomiting suggest?
A
Low intestinal obstruction or presence of gastrocolic fistula.
11
Q
What is faeculent vomiting?
A
Vomiting of faeces.
12
Q
What is Haematemesis?
A
Vomiting of blood
13
Q
What are early morning nausea and vomiting both caused by?
A
Pregnancy, Alcohol dependence and some metabolic disorders such as Uraemia.
14
Q
What is the main cause of persistent nausea when it is by itself and no other complaints are present?
A
Stress related.
15
Q
What is flatulence?
Causes?
A
Loads of farting. Big wind.
ii. high intake of carbonated drinks and high-fibre diet.
16
Q
What is organic abdominal pain caused mainly by?
A
Stretching of smooth muscle or organ capsules.
17
Q
What does bloody diarrhoea suggest?
A
Colonic and/or rectal disease.
18
Q
What does acute diarrhoea which lasts 2-3 days suggest?
A
Infective cause.
19
Q
What is epigastric pain most likely caused by?
A
- Food intake pain
- Dyspepsia
- Peptic ulcer disease
20
Q
What is a common symptom of gastro-oesophageal reflux.
A
Heart burn.
21
Q
What are the two main places of origin for right hypochondrial pain?
A
- Gall bladder and bilary tract.
22
Q
What two main diseases can present with pain in the right hypochondrium?
A
- Hepatic congestion
2. Peptic ulcer disease
23
Q
Pain in the left iliac fossa mainly associates with what area?
A
if acute then mainly colonic origin e.g. acute diverculitis
If chronic mainly functional bowel disorders.
24
Q
What are the main causes for pain in the right iliac fossa?
A
- Acute appendicitis
- ileocaecal disease
- Functional bowel disorders
25
What is proctalgia fugax?
Severe deep pain deep in the rectum that comes on suddenly but lasts only for a short time.
26
What are causes of abdominal wall pain which has localised tenderness ?
1. Muscle pain
If not relieved by tensing then probably from wall itself
1. Nerve entrapment
2. external hernias
3. Entrapment of internal viscera
due to traumatic or surgical alterations of abdominal wall musculature
27
Anorexia is usually a late symptom of cancer true or false
true.
28
What is the main cause of weight loss in malabsorption?
anorexia.
29
What is the main cause of weight loss with normal or increased dietary intake?
Hyperthyroidism.
30
What are the five fs related to abdominal distention?
```
Flatus
Fat
Fetus
Fluid
Faeces
```
31
What is intermittent distention a common feature of ?
Functional bowel disorders.
32
What are the 9 regions of the abdomen?
1. Epigastrium
2. Right/left hypochondrium
3. umbilical
4. Right and left lumbar
5. Hypogastrium
6. Right/left iliac fossa
33
What is Ascites?
Excess fluid in the peritoneal cavity.
34
How can you prove Ascites is present?
Asking patient to move on their sides. Causes shifting dullness. Dullness from flanks will move. This suggests 1-2 L of fluid present.
35
What does a succussion splash suggest?
Gastric outlet obstruction if patient has not drunk in 2-3 hours.
36
What is a proctoscopy used for?
To look for anorectal pathology such as haemorrhoids.
Patients with a history of bright red rectal bleeding.
37
What is a sigmoidoscopy used for?
routine examination when patient presents with diarrhoea and lower abdominal symptoms e.g. rectal bleeding.
38
What are the two types of idiopathic aphthous ulcerations?
Minor and Major.
39
What are characteristics of minor aphthous ulcerations?
the common type. Grey/white centre less than 10 mm. Heals within 14 days usually without scarring.
40
What are the characteristics of major aphtous ulcerations?
Bigger than 10 mm persistent for weeks/months. Heal with scarring.
41
What are the potential causes of mouth ulcers?
1. GI diseases ( e.g. Inflammatory bowel disease)
2. Infection : viral- HSV and HIV
Fungal- canidaisis
Bacterial- TB and syphilis
3. Systemic disease: reactive arthritis
Behcet syndrome
4. Trauma e.g. dentures
5. Neoplasia e.g. squamous cell carcinoma
6. Drugs e.g. ereythma multiforme major.
7. skin disease e.g. pemphigoid and pemphigus
42
Describe the characteristics of squamous cell carcinoma of the mouth.
Majority develop at floor of the mouth or lateral borders of the tongue.
Advanced tumours are hard, indurated ulcers with raised and rolled edges.
43
What are the aetiological agents of squamous cell carcinoma of the mouth?
1. Tobacco
2. heavy alcohol consumption
3. areca nut
4. HPV 16
44
What is the treatment of squamous cell carcinoma?
Surgical excision
neck dissection to potentially remove lymph nodes and/or radiotherapy.
45
What causes transient white patches?
Candida infection or due to systemic lupus erythematosus.
Local causes are trauma from drugs e.g. ill fitting dentures or aspirin.
46
What are persistent white patches caused by?
Leukoplakia - premalignant.
47
What are the causes for oral pigment lesions?
Peutz-Jeghers syndrome and Addison disease.
Heavy metals e.g. lead and drugs e.g. phenothiazine
48
What is glossitis?
Red,smooth sore tongue.
49
What is the cause of glossitis
iron,folate and Vitamin B12 deficiency
50
What is geographic tongue?
It is harmless migratory glossitis where ulcer like lesion forms changing colour and size.
Not related to cancer at all
51
What is gingivitis?
Inflammation of the gums
52
What are the causes of gingivitis?
Chronic
Bacterial plaque
Acute
spirochaete and fusiform bacteria ( poor hygiene and smoking)
gingival inflammation- pregnancy, scurvy and drug induced
53
How do you treat gingivitis ?
bacterial plaque- plaque removal
acute- oral metronidazole and chlorhexidine
54
What is the main bacteria which causes tooth decay?
Streptoccous mutans
55
What is xerostomia?
dry mouth.
56
What are the cause of xerostomia?
1. Sjogren syndrome and mikulicz
2. Drugs - antimuscarinic.
3. radiotherapy
4. dehydration
57
What do tertiary contraction of peristalsis in the oesophagus suggest?
Pathogenic non propulsive contractions. Caused by local reflexes within the myenteric plexus
58
What is dysphagia?
Difficulty swallowing.
59
What is odynophagia?
Pain in swallowing.
60
What does odynophagia suggest?
Oesophagitis
61
What are the characteristics of heartburn?
retrosternal burning pain that can spread to the neck and across the chest.
Can be difficult to distinguish from the pain of ischaemic heart disease.
Worst lying down at night- when gravity promotes reflux.
62
What does regurgitation suggest?
Gastro-oesophageal reflux disease or organic stenosis.
63
What is the main sign of oesophageal disorder?
Weight loss
64
What are ways of investigating oesophageal disorders?
1. Barium swallow meal
2. Gastroscopy
3. Manometry
4. Ambulatory pH monitoring
5. Impedance
65
Why does acid reflux increase with Gastro-oesophageal reflux disease (GORD)?
Due to increased transient lower oseophageal sphincter relaxations.
66
What are the two main forms of IBD?
Crohns disease
Ulcerative colitis
67
What is the epidemiology of IBD?
Highest incidence rates are in Northern Europe and North America. With Jewish population having highest ethnic rate.
68
What is the main cause of IBD?
Unknown. However it is associated with many co factors.
1. Genes
2. Environment
3. Intestinal micobiota
4. Host immune response.
69
What are the major genetic factors associated with IBD?
1. NOD2 gene- found on chromosome 16 also present in bacterial cell wall. Expressed in epithelial and macrophages. Increases risk of developing CD
2. Autophagy genes
3. Th17 pathway
70
What are the major enviromental factors of IBD?
1. Smoking
2. NSAIDS
3. Hygiene
4. nutritional factors
5. Psychological factors e.g. chronic stress and depression
71
What are the mechanisms of intestinal microbiota which may relate to IBD?
1. Intestinal dysbiosis - less diviersity of bacteria in guy e.g. more E.coli
2. Specific pathogenic organisms- increased E.Coli found in ileal epithelial cells in Crohn's disease.
3. Bacterial antigens
4. defective chemical barrier
5. Impaired mucosal barrier function.
72
What part of the GI tract is Crohn's disease most prominent?
The Terminal ileum and ascending colon. (ileocolonic disease)
73
Does Crohn's disease only cover one area?
It can however it can also display two other patterns
1. Skip lesions- effect certain areas of Gut with healthy bowel inbetween
2. Total colitis- can effect whole of colon.
74
What is the name given when IBD affects the rectum alone?
Proctitis.
75
What is the name given when IBD affects rectum and extends proximally to involve sigmoid and descending colon.
left-sided colitis.
76
What is the name given when IBD affect the whole colon?
Extensive colitis
77
What are the three main sites of UC?
ii. what is the most common site of UC
1. Extensive colitis
2. Distal colitis ( left sided colitis)
3. Proctitis
ii. Rectum
78
What are the macroscopic changes of Crohns disease?
1. The involved bowel is thickened and narrowed.
2. Deep ulcers and fissures in the mucosa produce a cobblestone appearance.
3. Potential intra-abdominal fistulae and absecesses may be seen.
4. Early feature -aphtoid ulceration in the colon.
79
What are macroscopic features of ulcerative colitis?
1. Mucosa is reddened and thickened and bleeds easily
| 2. Severe cases - extensive ulcerations with adjacent mucosa appearing as post-inflammatory polups.
80
What are macroscopic features of fulminant colonic disease of either UC or CD?
Most of mucosa is lost.
Formation of mucosal islands (oedematous mucosa)
toxic dilation occurs.
81
What are the microscopic features of CD?
Inflammation extends through all layers (transmural) patchy
Increase in chronic inflammatory cells and lymphoid hyperlplasia
Glanulomas present in roughly half of patients.
82
What are the microscopic features of UC?
Inflammation is limited to the mucosa. Continuos
chronic inflammatory cells infiltrate lamina propria.
crypt abscesses and goblet cell depletion seen
Rare for granulomas to be seen
83
What are the two types of peripheral athropathies?
1. Type 1 ( pauciarticular)- Acute and self-limiting
| 2. Type 2 (polyarticular)- chronic. usually associated with uvetitis.
84
Give examples of extragastrointestinal manifestations of IBD?
1. Eyes e.g. uvetis and conjunctivitis
2. Joints- type 1 and 2 arthropathy
3. Skin e..g erytherma nodosum
4. Liver and biliary tree e.g. scelrosing cholangitis, fatty liver,chronic hepatitis,cirrhosis and gallstones
5. Nephrolithiasis
6. Venous thrombosis
85
Give the main infective and non-infective causes of diarrhoea?
Non infective
1. IBD
2. Colitis
3. Behcet isease
4. Diverticular disease
5. malabsoprtion
6. Drugs e.g. laxatives, statins, metforming
Infective.
1. Bacteria
e. g. Campylobacter jejuni, salmonella,shigella, E.Coli, Staphylococcal enterocolitis
2. Virus e.g. rotavirus
3. Fungal e.g. histoplasmosis
4. Parasitic e.g. Amoebic dysentery
86
when should Crohns disease be considered with patients that have diarrhoea ?
1. Symptoms persisting beyond 5 days
2. Vitamin malabsorption
3. malnourishment
4. children with reduced growth velocity.
87
What are the symptoms of Crohns disease?
1. Diarrhoea
2. Abdominal pain
3. Weight loss
4. Malaise
5. Lethargy
6. Anorexia
88
What are the main presenting features with children who have CD?
Reduced growth velocity
delayed puberty
89
What is steatorrhea ?
Faeces containing fat.
90
Describe the stool of a patient with CD?
Diarrhoea. usually contains blood
Steatorrhoea is present in small bowel disease.
91
What are the physical signs of CD?
Weight loss
signs of malnutrition
Apthous ulcerations
tender abdomen with /or right iliac fossa mass occassional found
92
What blood test results would you find with someone with CD?
Anaemia is common- >100g/L of haemoglobin
Raised ESR-An erythrocyte sedimentation rate (ESR) is a type of blood test that measures how quickly erythrocytes (red blood cells) settle at the bottom of a test tube that contains a blood sample. Normally, red blood cells settle relatively slowly. A faster-than-normal rate may indicate inflammation in the body
Raised CRP-C-reactive protein (CRP) is a blood test marker for inflammation in the body. CRP is produced in the liver and its level is measured by testing the blood. CRP is classified as an acute phase reactant, which means that its levels will rise in response to inflammation
Hypoalbuminaemia
Serological test- negative perinuclear ANCA but positive ASCA
93
What imaging and endoscopy should be carried out with CD?
1. Colonoscopy- if colonic involvement suspected. Except if presenting with severe disease.
2. Upper gastrointesitinal endoscopy- exclude oesophageal and gastroduodenal disease.
3. Small bowel imaging - mandatory
4. Ultrasound- radiation free imaging for assessing disease activity in the ileum and colon.
94
What is the main treatment for CD?
Glucocorticosteroids. Used to induce remission.
(oral prednisolone 30-60 mg/day).
Exclusive enteral nutrition- mainly used for paediatric practice.
95
What are the symptoms of Hepatitis A?
1. Lethargy
2. Headaches,
3. Fever
4. Nausea
5. Abdominal pain
6. Jaundice
Incubation- 2-6weeks typically 28 days
96
What are the type of treatments used to induce remission of crohns disease?
1. Steroids
2. enteral nutrition
2. Anti -TNF treatment e.g. infliximab and adalimumab
97
What are the type of treatments used to maintain remission?
1. immunosuppresive e.g. azathioprine.
| 2. Anti- TNF
98
Smoking cessation will dramatically decrease risk of CD true or false?
TRUE
99
What are the indications of surgery with CD?
1. Failure of medical therapy
2. Complications e.g. enterocutaneous fistula, toxic dilation
3. Presence of perianal sepsis
100
Describe the procedures that can be carried out for crohns disease.
1. Strocturoplasty- strictures can be widened in small bowel disease
2. Resection and anastomosis. Need an ileocolonoscopy to access the anastomosis for disease recurrence
3. If Colonic CD involves whole colon and the rectum is spared, a subtotal colectomy and ileorectal anastomosis may be performed.
101
What is anastomosis surgery?
Surgical joining of two hollow organs,such as different part of intestine or blood vessels,in order to bypass disease or resected tissue.
102
What are the complications of crohns disease?
1. stricture formation
2. fistula formation
3. obstruction
4. pyoderma gangrenosum
5. anaemia
6. osteoporosis
103
What is the terminology given when examination of colectomy specimen des not lead to a diagnosis of CD or UC?
Indeterminate colitis
104
What is the main difference between CD and UC?
CD can be found anywhere along the GI tract
UC never spreads proximal to the ileocaecal valve.
105
What are the main symptoms and signs of UC?
5Ps
1. Pyrexia (fever)
2. pseudopolyps
3. lead pipe radiological appearance
4. Poo (bloody diarrhoea)
5. proctitis- frequent passage of blood and mucus, urgency and tenesmus
106
List symptoms of UC.
1. diarrhoea with mucus and blood (MAJOR symptom)
2. Lower abdominal discomfort
3. malaise
4. Lethargy
5. Anorexia
6. Weight loss
7. apthous ulcerations
note symptoms 3-6 not as severe as with CD
107
What is the relationship of smoking with UC?
UC is 3 fold as common in non smokers than smokers. Opposite for CD.
108
What defines a sever attack of ulcerative colitis?
1. Stool frequency : >6 stools/day with a lot of blood
2. Fever: >37.8
3. Tachycardia ( >90b.p.m)
4. ESR: >30mm/h
5. Anaemia: <100 g/L of haemoglobin
6. Albumin <30g/L
109
What are the complications of UC?
Acute: Toxic megacolon- Gas filled and contains mucosal islands. Xray shows colon is thin-walled and a diameter >6cm.
chronic: colonic cancer
110
What tests are used for UC
white cell count and platelet count- commonly raised
moderate to severe attacks- iron deficiency anaemia and hypoalbyminaemia
ESR and CRP often raised
pANCA- positive
111
How should you exclude infectious colitis?
stool tests.
112
WHat imaging shoud be used for UC?
Plain x-ray
ultrasound- inflammation of colonic wall.
113
How to differentiate betwen mild,moderate and severe UC?
Predominantly based on stool motion per
day
Mild - less or equal to 4
moderate 5
severe- 6 or more.
114
What is the main treatment of UC?
1. 5-ASA e.g. mesalazine - causes agranulocytosis
2. Steroids- prednisolone
3. Anti TNF agent
4. immunosupressants.
115
How do you treat mild UC?
5- ASA-mainstay for induction and maintenance of remission
topical steroid foams per rectum or prednisolone 20mg retention enemas.
116
How do you treat moderate UC?
1. Oral prednisolone for induction 40mg/day for 1 weeks then taper by 5mg/week over following 7 weeks
2. Maintain with 5-ASA
117
How to treat severe UC?
1. IV hydration/electrolyte replacement , IV steroids e.g. hydrocortisone and heparain to prevent thromboembolism
2. daily testing
3. If worsen use anti TNF then if fails urgent colectomy
4. IF improving transfer to Prednisolone
118
What is salvage therapy?
what are the requirements?
Medication to try and avoid colectomy.
CRP >45mg/L and 8 or more bowel motions after 3 days of IV Hydrocortisone
119
What happens in salvage therapy?
Occurs with use of ciclosporin as a continuos infusion or anti TNF induction and maintenance therapy.
More ulcerations= more TNF induction
120
What are the indications of surgery for UC?
```
acute:
failure of medical treatment
Toxic dilation
haemorrhage
imminent peforation
```
chronic
Incomplete response to treatment/steroid dependent
dypslasia on surveillance colonoscopy
121
What surgical operations are used in UC?
Subtotal colectomy and terminal
ileostomy
At a later date two options:
1. Proctectomy with a permanent ileostomy -
to avoid permanent ileostomy use ileo-anal pouch. Risk of pouchitis though.
122
What are the causes of Gastro-oesophageal reflux disease? (GORD)
1. Low Lower oesophageal sphincter pressure
2. Increased abdominal pressure
3. More tranient lower oesophageal sphincter relaxations
3. Sliding hiatus hernia
4. Rolling hiatus hernia
5. Oesophageal dysmotility (systemic sclerosis)
6. gastric acid hypersecretion
7. smoking and alcohol
123
What is the difference between sliding and rolling hiatus hernias?
Sliding- gastro-oesophageal junction slides up into chest. Acid reflux able to occur due to incompetence of LOS.
rolling- Gastro-oesophageal junction remains in the abdomen but of a bulge of the stomach herniates up into chest alongside the oeophagus. GORD is less common with this as junction remains intact.
124
What are the symptoms of GORD?
1. Heartburn- sensation made worse by lying down, stooping , drinking alcohol , hot drinks or after a heavy meal
2. Regurgitation of food and acid
3. waterbrash- extra salivation
4. odynophagia
5. Nocturnal asthma - cough
6. Laryngitis
125
How can you differentiate between GORD and cardiac ischaemia?
1. GORD pain very rarely radiates to arm while it happens with ischaemia
2. GORD is relived by antaacids while cardiac ischaemia isn't
126
What are the complications of GORD?
1. Oesophagitis
2. Ulcers
3. Benign strictures
4. Barrett's oesophagus.
127
What are the four grades of oesophagitis?
A- mucosal breaks confined to the mucosal folds,each no longer 5 mm
B- at least one mucosal break longer than 5 mm confined to the mucosal fold but not continuous between two folds.
C- Mucosal breaks that are continuous between the tops of mucosal folds but not circumferential
D- Extensive mucosal breaks engaging at leats 75% of oesophageal circumference.
128
What is Barrett's oesophageous?
When squamous epithelium in the oesophageous is replaced with metaplastic columnar mucosa to form 'columnar-lined oesophagus' CLO.
129
What are the clinical features of barrett's oesophageous?
Can be seen as a continual circumferential sheet
can be seen as finger like projections extending upwards from the squamocolumnar junction
can be seen as islands of columnar mucosa intersperse with areas of squamous mucosa.
130
obesity is a major risk factor for Barret's oesophageous true or false?
true.
131
What is the likelihood of Barrett's oesophageous causing oeophageal adenocarcinoma?
While B.O is premalignant, it shows a 1% risk in a typical patient.
132
How do you differentiate between high grade and low grade dysphagia with B.o?
HGD is usually associated with endoscopically visible nodule or ulcerations.
133
How do you investigate Barrett's oesophageous?
Endoscopy with biopsy in all four quadrants of CLO.
134
How do you treat Barrett's oesophageous?
1. Endoscopic mucosal resection
2. endscopic submucosal dissection
3. Surgical oesophagectomy
first 2 treatments used to prevent third.
Following removal of all known nodular or lesions.
4. RADIOFREQUENCY ABLATION IS USED this is the endoscopic treatment for dysplasia.
135
How do you investigate GORD?
1. If there is dysphagia and the patient is younger than 55, use endoscopy to assess oesophagitis and hiatus hernia.
2. 24 hour intraluminal pH monitoring or with manometry help.
ph <4 or >14.72 indicates reflux.
If patient older than 55 and doesn't have dysphagia just treat with drugs
136
What is the treatment for GORD?
Lifestyle: Weightloss, stop smoking, raising bed head at night.
Drugs
Antacids- form a gel with gastric contents to reduce reflux e.g. magnesium trisilicate, aluminum hydroxide
H2-receptor antagonists- acid supression e.g. cimetidine and ranitidine
PPI-inhibit gastric hydrogen. Main choice for mild cases by doctors. e.g. omeprazole and rabeprazole
patients who do not respond to PPI and still have symtpoms are described as having non-erosive reflux disease (NERD)
surgery
1. laparoscopic Nissen fundoplication
2. lapararoscopic insertion of a magnentic bead band.
These are used to increase LOS sphincter pressure
137
What can potentially happen if carbohydrate, protein and liver metabolism is disrupted?
1. Fatigue
2. weight loss
3. muscle atrophy
4. Hypoalbuminaemia
5. Hypoglycaemia
6. Reduced coagulation factors
138
How does hypoalbuminaemia cause oedema?
Reduction in plasma oncotic pressure allows for extravasation of fluid from capillaries into tissues.
139
What does reduced clotting factors cause ?
coagulopathy which will cause a prolonged prothrombin time
140
Why is PT more important than albumin as a test for deteriorating liver function?
as coagulation factors have a half-life for a few hours whereas albumin has have a half-life for 21 days.
Therefore a prolonged prothrombin time is a more sensitive reading
141
what does prothrombin time measure?
How quickly it takes blood to clot.
142
What are the main causes unconjugated hyperbilirubinaemia?
1 Prehepatic jaundice
2. hepatic jaundice
note liver diseases seldom cause unconjugated hyperbilirubinaemia
143
What are the main causes of conjugated hyperbilirubinaemia?
1. Post hepatic jaundice
| 2. Hepatic jaundice
144
What differentiates between hepatic jaundice ( intrahepatic cholestasis) and the other two forms of jaundice?
Intrahepatic cholestasis - no macroscopic obstruction in the hepatic biliary system
both forms of bilirubin concentrations also typically increase
145
What are the causes of gallstones?
1. too much absorption of water in gallbladder
2. Too much absorption of bile acids in gallbladder
3. Too much fat in bile
4. Inflammation of epithelium in the gall bladder.
146
What are the clinical uses of Bile acid sequestrants?
hyperlipidaemia (limited effect)
cholestatic jaundice (itch)
bile acid diarrhoea
147
What are the adverse effects of bile acid sequestrants?
1. unpalatable, inconvenient (large dosages)
2. frequently cause diarrhoea
3. reduced absorption of fat-soluble vitamins, and some drugs (e.g. thiazide diuretics)
148
Haemolytic disorders cause what type of jaundice?
Prehepatic
149
Biliary obstruction causes what type of jaundice?
Post hepatic
150
What is the cause of hepatic encephalopathy?
hyperammonaemia (acute)
Toxin absorption ( chronic) hyperammonaemia too
151
Describe the effect of heperammonaemia on the brain?
astrocytes in the brain removes ammonia by converting glutamate to glutamine
Glutamate + ATP + NH3 → Glutamine + ADP + phosphate
The excess glutamine causes an osmotic imbalance and a shift of fluid into these cells causing cerebral oedema.
152
What are the effects of hepatic encephalopathy?
Grade 1- altered mood, sleep disturbance
grade 2- increased drowsiness ,confusion , slurred speech and liver flap
grade 3- incoherent
grade 4 - coma.
153
How do you treat hepatic encephalopathy
lactulose (laxative)
antibiotics (neomycin, rifamixin)
154
What does Ezetimibe treat?
hypercholesterolaemia - binds to NPC1L1 which stops cholesterol absoprtion
155
What issues may arise if bile salts arent able to be secreted?
1. Steatorrhoea
| 2. secondary vitamin deficiency
156
What does vitamin A deficiency cause?
night blindness and dermatitis
157
What does vitamin D deficiency cause?
Osteomalacia
rickets
158
What does vitamin K deficiency cause?
Coagulopathy
159
What does Vitamin C deficiency cause?
scurvy
160
What procedure is used to drain ascitic fluid from the peritoneal cavity?
paracentesis
161
Where must the needle be placed during paracentesis?
ii. why is this?
1. must be placed Lateral to the rectus sheath
ii Avoids the inferior epigastric artery
162
What can equipment can be avoided to make sure the inferior epigastric artery is not punctured?
use ultrasound
163
What is the difference in characterisation of visceral pain vs somatic ( parietal pain)
1. Visceral- tends to be dull, achy and nauseating
| 2. Parietal- tends to be sharp and stabbing
164
Where does foregut pain tend to be felt in?
epigastric region
165
Where does midgut pain tend to be felt in?
umbilical region
166
Where does foregut pain tend to be felt in?
Pubic pain
167
Why is the spleen and liver timed with patients breathing when you palpate it?
as they are anatomically related to diaphragm so they moves when the muscle moves
168
Due to the properties of the functional segments of the liver what type of surgery can be performed?
Segmentectomy
169
what is the name of the surgery to remove the gallbladder?
cholecystectomy
170
what might be a potential hazard while performing the cholescystecomy?
there is a variation in the origin and course of the cystic artery in 25% of people
171
Where can pain in the gallbladder present?
hypochondrium- with or without pain referral to the right shoulder
172
where will early pain from gallbladder inflammation present?
epigastric region
173
What is an ERCP used for?
Investigate the biliary tree and pancreas
pathology wise can be used to remove gallstones
174
How does an ERCP work?
Endoscope inserted through oral cavity- then through to duodenum
cannula placed in the major duodenal papilla - radio opaque dye inserted into biliary tree
radiographic images taken of due-filled tree
175
What is the inflammation of the pancreas called?
pancreatitis
176
which region of the abdomen is pancreatic pain detected?
umbilical and/or epigastric- as it is midgut and foregut
Can radiate through to the patients back
177
What region of the abdomen is small intestine pain found?
epigastric
178
What can sigmoid volvulus cause?
bowel obstruction which can lead to infarction
179
what causes the opening of the ligamentum teres?
portal hypertension due to liver pathology (eg cirrhosis)
180
Why do the portal systemic anastamoses become dilated? (ie how do varices form)
portal hypertension, causing collateral veins to receive a higher volume of blood
181
What are the clinical presentations of portal hypertension?
1. oeosphageal varicies- dilated submucosal collateral veins
2. caput medusae- dilated collateral veins and epigastric veins
3. rectal varicies
182
What are the differences between rectal varices and haemorrhoids?
1. varices form in relation to portal hypertension
2. Haemorrhoids- prolapses of the rectal venous plexus due to raised pressure from chronic constipation,staining or pregnancy
183
How can faecal constipation form due to labor?
Branches of pudendal nerve potential stretched- leaves to fibres within puborectalis or external anal sphincter to be torn
therefore weakened muscle
184
What is an ischioanal absess?
infection of the ischioanal fossae
185
How do you exam the effectiveness of the external anal sphincter?
ii what do you palpate?
PR exam
ii Male- prostate anteriorly
Female- palpate the cervix
186
what is a proctoscopy used for?
Viewing anterior of the rectum
187
What is a sigmoidoscopy used for?
viewing the interior of the sigmoid colon (quicker than colonoscopy)
188
What is a colonoscopy used for?
Viewing interior of the colon
189
How should aphthous ulcers be managed?
No specific therapy
Sufferers avoid:
1. oral trauma
2. acidic drinks
can take:
3. Tetracycline or antimicrobial mouthwash
4. topical analgesia
5. corticosteroid for severe ulcers
Biopsy any ulcer if haven't healed after three weeks to exclude malignancy
190
What is candidiasis?
also known as thrush. causes white patches or erythema of the buccal mucosa.
hard to remove white patches- can cause bleeding if removed
191
What are the risk factors for candidiasis?
Age
antibiotics
immunosuppression ( long term corticosteroids and inhalers)
192
How do you treat candidiasis?
miconazole gel
193
What is microstomia?
Small narrow mouth- thick and tight perioral skin
194
What are the causes for microstomia?
burns
systemic sclerosis
195
What is angular stomatitis?
Fissuring of the mouths corners
196
What are the causes of angular stomatitis?
Denture related problems
deficiency of iron
riboflavin
197
what are the main risk factors for oral cancer?
```
age
tobacco
alcohol
diet/nutrition
previous head/neck cancer (especially in last 2 years)
HPV
Ultra Violet Light
candida
(syphylis
other dental factors)
```
198
what is the ratio of men: women for oral cancer?
2:1
199
what is lichen planus?
a white lacy looking atrophy, cause is unknown
200
why might oral cancer cause a numb face/lip or drooping eye lid/facial palsy?
cancer targeting a cranial nerve
201
when can lichen planus become a pre-malignant condition?
when it become erosive
202
What is achalasia?
Degenerative loss of ganglia from Auerbach’s plexus
oesophageal motility disorder. Oesophageal aperistalsis and impaired relaxation of LOS has occured
203
What are the signs and symptoms of achalasia?
1. intermittent Dysphagia from both liquids and solids
2. Regurgitation of food
3. weight loss can occur
204
How do you diagnose achalasia?
manometry- shows aperistalsis
contrast barium swallow - shows lack of peristalsis and synchronous contractions in the body of the oesophagus.
Chest x ray- shows dilated oesophagus (bird beak at distal oesophagus)
205
How do you manage achalasia?
Treatment is palliative
Endoscopic dilation of LOS using a balloon . repeat giving botulinum toxin injections to prevent perforation
or
Heller's operation- surgical division of LOS. PPIs needed afterwards
206
What is diffuse oesophageal spasm?
Severe form of oesophageal dysmotiliy.
207
What are the signs and symptoms of diffuse oesophageal spasm?
Intermittent dysphagia
chest pain ( usually retrosternal)
marked contractions of oesophagus without peristalsis
can be asymptomatic- particularly over 60
208
What disease can diffuse oesophageal spasm beassociated with?
GORD
209
How do you diagnose oesophageal diffuse spasm?
Contrast barium swallow- shows corkscrew oesophagus
manometry
210
How do you manage oesophageal spasm
PPIs if reflux is present
antispasmodics
nitrates
calcium channel blockers
balloon dilation sometimes used
211
What are the causes of benign oeosphageal strictures?
1. GORD- main one
1. ingestion of corrosives
2. radiotherapy
212
what is a mallory weiss tear?
A linear mucosal tear at the oesophagogastric junction.
213
What are the signs and symptoms of the mallory weiss tear?
Persistent vomiting which then leads to haematemesis
Tends to occur after alcoholic dry heaves
214
How do you diagnose Mallory-weiss tear?
gastroscopy
215
how do you manage a mallory-weiss tear?
usually nil active
endoscope guidance for clipping
or surgery for oversewing- rarely needed
216
Give the main specific associated diseases/causes of dysphagia.
1. MALIGNANT STRICTURE ( pharyngeal cancer, oesophageal cancer or gastric cancer)
2. benign stricture ( esophageal web or peptic stricture)
3. achalasia
4. oepshageal spasm
5. oesophagitis
6. globus
7. bulbar palsy
8. extrinsic pressure ( lung cancer, mediastinal nodes or aortic aneurysm)
217
What signs can be associated with dysphagia?
1. anaemic
2. weight loss
3. cachexia
4. Virchow's node- suggest intra abdominal malignancy
5. pharyngeal pouch forms when drinking (very rare)
218
What tests should be carried out with dysphagia?
1. FBC
2. U&E - for dehydration
3. Endoscopy and biopsy
4. oesophageal manometry-measures pressures generated in the oesophagus
219
what key questions should be asked in relation to dysphagia?
ii. What would different answers tell you to each question?
1. Was there difficulty swallowing solids and liquids from the start?
yes= motility disorder
No= solids before liquids- stricture more likely
2. is it difficult to initiate a swallowing movement?
Yes= bulbar palsy
3. Does odynophagia occur?
yes=Ulceration- think of their causes
4. Is the dysphagia constant or intermittent?
follow on by does the pain get worse?
Constant and gets worse= malignant stricture
intermittent= oesophageal spasm
5. does the neck bulge or gurgle on drinking?
yes- pharyngeal pouch
220
what is eosinophilic oesophagitis?
inflammation in the oesophagus caused by presence of eosinophils
also called allergic eosinophilic
221
What are the signs and symptoms of eosinophilic oesophagitis?
Dysphagia
food impaction
heartburn
oesophageal pain
more present in young (average 35) white men
222
How do you diagnose eosinophilic oesophagitis?
Endoscope to look for:
schatzki's rings
thickened mucosa and mucosal furrowing
endoscopic biopsies
pH probe negative for reflux
223
how do you manage eosinophilic oesophagitis?
Topical steroids( fluticasone spray)- if not effective then use systemic steroids
224
What are the two histological subtypes of oesophageal cancer?
Squamous cell carcinoma (most common)
Adenocarcinoma
225
Where do these two cancers occur in the oesophagus?
SCC- Upper and middle third
Adenocarcinoma- distal third ( and cardia of the stomach)
226
What are the main risk factors for the both types of cancers?
SCC
1. Smoking
2. alcohol
3. plummer-vinson syndrome
4. achalasia
5. corrosive strictures
Adenocarcinoma
1. Longstanding heartburn
2. Barrett's oesophagus
3. Smoking
4. obesity
5. older Age
227
What are the epidemiology of both types of cancers?
SCC- more common in ethiopia,china,south and east Africa and the caspian sea region off iran
More common in men
Adenocarcinoma- West - more common in men
228
What are the signs and symptoms of carcinomas in the oesophagus?
Signs:
1. Weight loss
2. Anorexia
3. lymphadenopathy
4. difficulty in swallowing
5. coughing
6. aspiration into the lungs
Symptoms
Dysphagia- constant and solids first to be found difficult to swallow then liquids
odynophagia
hoarseness
229
How do you diagnose carcinomas of the oesophagus?
Endoscopy with biopsy
barium swallow
CT/MRI/US/Laparoscopy/PET for staging of tumour
230
what are the different tumour staging for carcinoma of the oesophagus?
Tis- carcinoma in situ
T1- invading submucosa
T2- invading muscularis propria
T3-invading adventitia
T4- invasion of adjacent structures- both local and distant metastasis
231
When is a laparoscopy used for staging of the tumor?
If tumour is at the cardia- looks for peritoneal and node metastases
232
When is a PET scan used for staging the tumour?
used to confirm distant metastases after use of CT and fluorodeoxyglucose
233
How do you manage the carcinomas of the oesophagus?
Depends on the patient and stage of disease
Surgery:
use if tumour has not infiltrated outside the oesophageal wall
oesophagectomy
or endoscopic mucosal resection
If localised T1/T2- radical curative esophagectomy
Pre Op chemotherapy: benefit stage 2b-3
Palliative: mainly for T4
chemo and radiotherapy
endoscopic dilatation
or
oesophageal stenting- helps drink food and solids
234
What are the benign oesophageal tumour called?
Squamous papilloma- rare
lipomas- very rare
Leiomyomas- very rare
235
What are squamous papiloma's symptoms and associated diseases?
asymptomatic
Associated with HPV
236
What is the main type of oesophagitis called?
reflux oesophagitis
237
What are the characteristics of reflux oesophagitis?
inflammation of oesophagus due to refluxed low pH of gastric content
Basal xone epithelial expansion
Intraepithelial,neutrophils,lymphocytes and eosinophils are present
238
What are the causes of reflux oesophagitis?
defective LOS
pregnancy
Abnormal oesophageal motility
all increase intra-abdominal pressure
239
What does reflux oesophagitis cause
chronic oesophagitis- most common form
ulceration
strictures
Barrett's oesophagus
240
what causes acute oeosphagitis?
corrosives
infection e.g. candidiasis, herpes
241
What symptoms make up dyspespsia?
Epigastric pain/burning (mainly retrosternal pain)
Postprandial fullness ( fullness after food)
Early satieity
tender epigastrium
242
What are the alarm symptoms?
Anaemia
Loss of weight
Anorexia
recent onset/progressive symptoms
Melanea/haematesis
swallowing difficulty
remember older than 55 is also a good indication
243
what are the two main types of dyspepsia?
organic
functional (non-ulcer)- no evidence of culprit structural disease via OGD
244
What are the main causes of organic dyspepsia?
Helicobacter pylori infection
Peptic ulcers ( gastric and duodenal)
Gastritis
Drug induced
gastric cancers
245
What is Helicobacter pylori
gram negative bacterium
246
Where is Helicobacter pylori most commonly found?
high in developing countries
acquired mainly in childhood
247
What does helicobacter pylori cause?
gastritis
peptic ulcer disease
Gastric cancers
asymptomatic patients
248
How do you diagnose Helicobacter pylori infection?
Serological tests- detect IgG antibodies ( specific and sensitive test) (FBC)
C-urea breath test- make sure no PPIs or antibodies have been taken in the past 2-4 weeks
Stool antigen tests- becoming most popular. first step of diagnosing
or
Gastric biopsies- if H.pylori is present the urease enzyme that the bacteria produce splits the urea to release ammonia
culture- Biopsies can be cultured on a a special medium for testing antibiotics
249
What would you do if the patient has dysphagia and/or the alarm symptoms for dyspepsia?
Use an upper GI endoscope
250
What would you do if the patient DOES NOT dysphagia and/or the alarm symptoms for dyspepsia?
stop drugs causing dyspepsia
change lifestyle
give antacids
review after 4 weeks- no improvement test for H.Pylori
251
What do you do if the test for H.pylori is negative?
Give PPI or H2 blockers for 4 weeks ( omeprazole or ranitidine)
no improvement?- consider endoscopy or longer term medication
252
What would you do if the test for H.pylori is positive?
eradication therapy
253
How do you treat H.pylori infection?
eradication therapy
Patient must be compliant
triple therapy is main form
1. omeprazole (PPI)+clarithromycin+amoxicillin
2. Omeprazole (PPI)+ Clarithromycin + metronidazole
either given for 7-14 days. 2 weeks increase risk of side effects and reduced compliance. but higher eradication rate
oral metronidazole has frequent side effects.
if patient has risk of perforation or haemorrhage test for h.pylori after treatment for 6 weeks
General treatment
stop smoking
biopsies may be required to see that ulcers have gone
254
what is gastritis?
inflammation associated with mucosal injury of the stomach
255
What are the causes of gastritis
1. H.pylori ( most common cause particularly in chronic)
2. Drugs ( especially NSAIDs most common cause for acute)
3. Autoimmune gastritis
4. Cytomegalovirus
5. Alcohol 9acute)
6. ingestion of corrosives
7. Crohns or sarcoidosis ( granulomas) -rare
256
What are the signs and symptoms of gastritis?
Epigastric pain
vomiting
257
What part of the stomach does autoimmune gastritis effect?
fundus and body
258
What does autoimmune gastritis cause?
Atrophic gastritis and loss of parietal cells and then onto pernicious anaemia
259
How does pernicious anaemia occur from atrophic gastritis?
Achlorhydria(absence of hydrochloric acid in the gastric secretions.)
and
intrinsic factor deficiency( no B12 absorption)
occurs
due to production of autoantibodies ( more common) for gastric parietal cells and for the intrinsic factor ( more important)
260
What is gastropathy?
epithelial cell damage in the stomach but no inflammation
261
WHat are the causes of gastropathy
1. Irritants ( NSAIDs and alcohol mainly)- main cause
2. bile reflux
3. chronic congestion
4. stress ulcers- acute these are secondary to; burns, trauma or shock
262
WHat is the main type of gastritis caused by H.pylori infection?
antral gastritis
263
What does gastritis potentially lead to?
metaplasia
264
What are the two main forms peptic ulcers
Duodenal ulcers ( more common)
gastric ulcers
265
Where do gastric ulcers mainly form?
Lesser curve of the stomach. elsewhere are often more malignant
266
What is the epidemiology of peptic ulcer disease?
more common in the elderly especially women
considerable geographical variation
267
What is a peptic ulcer?
consists of break in the superficial epithelial cells penetrating down to the muscularis mucosa of either the stomach or the duodenum
268
Where do duodenal ulcers mainly form?
Duodenal cap- duodenitis occurs to the surrounding mucosa
269
What are the causes of peptic ulcer disease?
1. H.pylori- main for both types
2. smoking
3. Drugs ( NSAIDS and steroids)
4. reflux of duodenal contents
5. delayed gastric emptying
270
What are the signs and symptoms of peptic ulcer disease?
1. Recurring burning epigastric pain
2. for some reason patient pointing to the epigastrium with ONE finger is a good sign of a peptic ulcer
3. DU pain normally occurs at night or when patient is hungry
4. Nausea
5. vomiting
6. weight loss
7. anorexia
8. epigastric tenderness
9. can be asymptomatic
271
How do you diagnose peptic ulcer disease?
Gastroscopy
test for H.Pylori infection
Measure gastrin concentration when off PPIs if there is suspected zolinger-ellison syndrome
Biopsy
272
How do you treat peptic ulcer disease?
stop drinking and smoking
Eradication therapy for H pylori infection
If no positive result for H pylori then use PPIs or H2 blockers
Drug induced ulcers: stop taking those drugs. PPIs useful for NSAID induced ulcers
surgery only used for recurrent haemorrhage or perforation
273
What are the complications of Peptic ulcer disease?
Haemorrhage
Perforation-More common with DUs
gastric outlet obstruction- main symptom is vomiting due to build up of gastric juice,ingested fluid and food. Occurs due to oedema around an active ulcer or because of scarring from a healed ulcer.
Malignancy
274
What is zollinger-ellison syndrome?
Gastrin secreting adenoma ( gastrinoma) causes excess amount of gastric acid to be secreted leading to formation of peptic ulcers.
275
Where are these gastrinomas found?
Mainly in the pancreas
but also in the stomach and duodenum
276
What are the symptoms of Zollinger-ellison syndrome?
Dyspepsia (mainly abdominal pain)
chronic diarrhoea/steatorrhoea - due to inactivation of pancreatic enzymes
277
How do you diagnose Zollinger-Ellison syndrome?
Increase in fasting gastrin level- hypochlorhydria should be excluded by recording ph ( hypochlorhydria causes pH 3-5 when it should be less than 2)
secretin stimulation test
Endoscopic ultrasound - for imaging
CT scan- localise and stage the adenoma
278
How do you manage zollinger-ellison syndrome
High dose of PPI
Surgery- may be avoided if adenoma is MEN1 as metastasis is rare
279
What are the three main types of malignant gastric tumours?
Adenocarcinoma
Lymphoma
Gastrointestinal stromal tumours (GISTs)
280
What is the epidemiology of adenocarcinoma of the stomach?
More common in men than women
High in Japan,china,columbia and finland
rare under the age of 30 (50-70 is the peak)
281
What are the causes of gastric Adenocarcinoma?
H. pylori infection (main cause)
dietary factors
Smoking
Pernicious anaemia
Genetic abnormality
282
What are two main types of gastric adenocarcinoma?
Intestinal - differentiated well-formed glandular structures. Polypoid or ulcerating lesions. Mainly in distal stomach. Slightly better prognosis
Diffuse- undifferentiated poorly cohesive cells. Involved in any part of the stomach but cardia is mainly where it forms. form signet ring sign
283
What are the signs and symptoms of gastric adenocarcinoma
50% at screening have no symptoms
Dyspepsia with Alarm symptoms.
Epigastric pain may be relieved by food and antacids
Palpable epigastric mass with abdominal tenderness is common
Palpable lymph node in the supraclavicular fossa ( Virchow's Node)
284
How do you diagnose Gastric adenocarcinoma?
Gastroscopy
Biopsy
CT scan of the chest and abdomen- stages cancer - limited ability to determine the depth of local tumour invasion
Endoscopic ultrasound
285
How do you manage gastric adenocarcinoma?
endoscopic mucosal resection for removal of non ulcerative mucosal lesions
Surgery is best form of treatment
palliative chemotherapy
286
What are GISTs?
subset of GI mesenchymal tumours
of stroma origin
287
How do you treat GISTs?
surgery main choice
tyrosine kinase inhibitor - chosen for unresectable or metastatic disease
288
What is Primary Gastric Lymphoma?
Mucosa associated lymphatic tissue tumours
Mainly B cell marginal zone lymphomas
289
What is the main cause for Primary Gastric lymphoma?
H.pylori infection
290
What are the signs and symptoms of gastric lymphoma?
Dyspepsia and Alarm symptoms
ulcers can be found
Rarely have systemic complaints ( fever or fatigue)
291
How do you treat Gastric lymphomas?
H.pylori eradication therapy
surgery and chemotherapy
good prognosis- 90% 5 year survival
292
What are the main features of GI bleeding?
Haematemesis
Melaena (sometimes accompanied with shock)
293
What does Melaena usually indicate?
bleeding from any lesion proximal to the right colon
294
What are the main causes of Upper GI bleeding?
Peptic ulcers
Mallory-Weiss tear
malignancy
Oesophageal varices
Gastritis
Drugs ( NSAIDs,aspirin,anticoagulants and steroids)
n.b Anticoagulation does not directly cause bleeding but an anticoagulated patient as a higher risk of bleeding.
portal hypertensive gastropathy (rare)
295
What are the signs of Upper GI bleeding?
Clammy hands
Capillary refill more than 2 seconds
look for signs of encephalopathy
Tachycardic
systolic BP greater than 100 mmHg
Postural drop > 20 mmHg
clinical signs of chronic liver disease
PR exam for meleana
Then calculate Rockall score
296
How do you manage Upper GI bleeding?
stop drug causing the bleeds
Make sure patient is given high flow O2
Take FBC U&E and LFT, clotting and crossmatch
Note Urea will greatly increase which is indicative of massive blood meal
1. Insert 2 large bore iv cannula to take blood
2. Give IV fluid to restore blood volume - avoid saline if cirrhotic
3. Give chest x ray and ECG
4. Continue monitoring pulse and BP and hourly urine output (catheter must be used)
5. Transfuse if patient is either in shock or hemoglobin has fallen below 70g/L
6. Give urgent endoscopy in shocked patients
7. If endoscopy fails then use surgery or emergency mesenteric angiography
sengstaken can be used as a backup - compresses varices
Treatment for varices:
1. Terlipressin- only vasoconstrictor proven to reduce mortality. Don't give to patients with ischaemic heart disease.
2. Endoscopy- confirm diagnosis and to exclude bleeding from other site.
With endoscopy variceal banding can occur- Bands oesophageal varice which sucks varix to end of the scope.
Balloon tamponade is only temporary allows for preparation of TIPS or Banding
TIPS
2. Acute Rebleed:
Transjugular intrahepatic portocaval shunt( TIPS)- used for rebleed or acute management. Creates total shunt decreasing both sinusoidal and portal vein pressures.
Far more effective at reducing rebleeding rates then endoscopic techniques
complication: Increase risk of encephalopathy
3. Primary prophylaxis ( patients with diagnosed cirrhosis and have varices that have not bled)
Endoscope to diagnose varices
Non selective beta blockers ( Propranolol and carvedilol)
If patients are tolerant or unreliable with beta blockers then use variceal band ligation.
4. Secondary Prophaylaxis ( survived variceal bleed)
Variceal banding ligation and Non selective beta blockers are both used at the same time not like primary which is a choice between the two.
Poor liver function: Liver transplant
Treatment for Peptic ulcer:
Antral biopsies should be taken to look for H.Pylori. If positive eradication therapy. If negative gastric Histology should be checked
for bleeding ulcers or ones with stigmata of recent bleeding- Inject with adrenaline and thermal coagulation ( heater probe or bipolar probe) or endoscopic clipping. Dual or triple therapy is better than monotherapy
All Patients with active bleeding ulcers should be given IV PPI
Further management
If repeat bleeding then perform endoscopy. DUs have higher risk as they are nearest to gastro duodenal artery
Continue to check FBC, U&E,LFT and clotting daily
Keep nil by mouth if high rebleed risk
only discharge patients within 24 hours if Rockall score pre endoscopy was 1 or post was 0
297
What are the causes of acute lower GI bleeding?
Diverticular disease
Ischaemic colitis
Hemorrhoids (common with smaller recurrent disease)
Anal fissure ( common)
Carcinoma
Polyps
IBD- often associated with diarrhoea
angiodysplasia
298
How do you diagnose lower Gi bleeding?
Proctoscopy- for anorectal disease
SIgmoidoscopy or colonoscopy- IBD, cancer and ischemic colitis
angiography- last resort as yield. of angiography is low
299
How do you manage Lower GI bleeding?
Most Lower GI bleedings start and stop spontaneously
use same principle for resuscitation for upper Gi if bleeding continues
300
What are the signs and symptoms of chronic GI bleeding?
Haematemesis
Meleana
Iron deficiency anaemia (for women it occurs mainly after menopause)
301
What are the main causes of chronic GI blood loss?
Lesions main cause ( benign or malignant ulcers)
Hookworm- uncommon in developed countries however
can be any cause of Acute upper or lower however oesophageal varices are a rare cause
302
How do you diagnose chronic GI blood loss?
Endoscopy performed for both upper and lower Gi tracts in order to find the site of bleeding
First UGE then colonoscopy.
Then biopsy lesions or remove them completely
IV colloid may be used to show potential site of bleeding in a meckel's diverticulum
303
How do you manage Chronic GI blood loss?
Oral iron for the anaemia
treat cause of the bleeding
give transfusion as last resort
304
what questions should be asked when taking a history for acute GI bleeding?
dypepsia?
known ulcers?
known liver disease/oesophageal varices?
serious comorbidity? bad sign ( cardiac failure, ischaemic heart disease, chronic kidney disease and malignant disease)
305
What are the clinical features of shock?
Pallor, cold peripheries, tachycardia and low BP, clammy hands
306
What are the two types of Functional dyspepsia?
Note there is overlap between the two
Epigastric pain syndrome- pain in the upper abdomen being the most annoying symptom
Postprandial distress syndrome- discomfort(not pain) centered in the upper abdomen as the main issue.
307
What is the main cause of functional dyspepsia?
No structural abnormality
308
How do you diagnose Functional dyspepsia
H pylori infection should be excluded via a stool antigen test
endoscopy for patients with alarm symptoms and older than 55
309
How do you treat functional dyspepsia?
H pylori eradication therapy shown to help
PPIs help with epigastric pain
Psychotherapy ( placebo response has high rates)
reassurance and explanation helps
lifestyle changes are effective too
310
what is gastroparesis?
delayed gastric emptying but with no physical obstruction
311
what are the symptoms of gastroparesis?
```
post-prandial fullnes
bloating
nausea
vomiting
weight loss
upper abdominal pain
```
312
what illicit drug is associated with gastroparesis?
cannabis
313
what medication is associated with gastroparesis?
opiates and anticholinergics
314
how do you investigate suspected gastroparesis?
gastric emptying studies
315
what is the management of gastroparesis?
```
removal of precipitating factors eg drugs
liquid diet
eat little and often
promotility agents
gastric pacemaker
```
316
diabetes is associated with gastroparesis true or false?
TRUE
317
What is sepsis?
Life threatening organ dysfunction due to dysregulated host response to infection
318
What is septic shock?
is a subset of sepsis in which underlying circulatory and metabolic abnormalities are profound enough to substantially increase mortality
319
What are the local signs of abdominal infection?
pain
tenderness
guarding
320
what are the systemic signs of abdominal infection?
fever
chills/rigors
nausea/vomiting
diarrhoea or constipation
malaise - from anorexia
321
How do you treat intra abdominal infection?
Empiric policy :
Amoxicillin ( for streptococci and enterococci)+ gentamicin ( for aerobic coliforms) + metronidazole (for anaerobes)
322
Discuss the SOFA score for sepsis from 0 to 4
Respiration: PaO2 decrease goes from 53.3 kpa at 0 to 13.3
Coagulation: platelets decrease from more than 150 to less than 20
Liver- bilirubin increases from 1.2 mg/dL to more than 12
cardio: MAP decreases from more than 70 mmHg to less
CNS: decreases from 15 to les than 6 ( glasgow coma scale)
Renal: creatine increases from less than 1.2 mg/dl to more than 5
323
What is sepsis 6
designed to lower mortality in patients with sepsis
1. give high low O2
2. give IV fluid resuscitation
3. take blood cultures
4. Give IV antibiotics
5. Measure lactate and FBC- high lactate implies higher level of care needed
6. monitor accurate hourly urine output- useful assessment of kidney perfusion
324
What are the causes of gastrointestinal malabsorption
Main: coeliac disease,chronic pancreatitis and crohn's disease
Rare:
decrease in bile; PBC and ileal resection
small bowel mucosa: whipple's disease, tropical sprue, small bowel resection, lactase insufficiency
Bacterial overgrowth: spontaneous and also in jejunal diverticular PPI IS A RISK FACTOR
infectious giardiasis
Gastrojejunostomy
325
What are the signs and symptoms of Gi malabsoprtion?
Diarrhoea
weight loss
lethargy
steatorrhoea
bloating
deficiency signs:anemia, bleeding disorders and oedema
326
How do you diagnose Gi malabsorption?
FBC ( mean cell volume increase)- anaemia
decrease in ca 2+
decrease in iron
decrease in B12 and folate
increase in INR
stool: sudan stains for fat globules as well as tool microscopy
endoscopy and small bowel biopsy
breath hydrogen analysis
327
What is coeliac disease?
inflammation of the mucosa of the upper small bowel that improves when gluten is removed from the diet.
less severe towards ileum as gluten is digested into smaller fragments
328
What occurs to the small intestine villi during coeliac disease?
villous atrophy- flat duodenum forms
crypt hyperplasia
enterocytes become cuboidal
presence of intra epithelial lymphocytes
329
What are the signs and symptoms of coeliac disease?
May mimc IBS therefore test these patients
stinky diarrhoea/steatorrhoea
abdominal pain
weight loss
mouth ulcers and angular stomatitis
malnutrition physical signs (iron deficiency and other minerals plus fat soluble vitamins)
dermatitis herpetiformis- remember
330
How do you diagnose coeliac disease?
small bowel biopsy is gold standard : subtotal villous atrophy intra epithelial lymphocytes and crypt hyperplasia. enterocytes become cuboidal
serology:
anti transglutaminase antibodies
decrease in haemoglobin
increase in RDCW
decrease in B12 and ferritin
HLA-DQ2 is present in 90-95% of coeliac disease
331
How do you manage coeliac disease?
Replace vitamins and minerals
Gluten-free diet for life
poor compliance will be main issue if failure to respond
some patients might have non-responsive coeliac disease
332
What is tropical sprue?
malabsorption and chronic diarrhoea that occurs in tropical areas . Villous atrophy is also present
333
How do you diagnose tropical sprue?
must exclude acute effective causes of diarrhoea
malabsorption should be demonstrated particularly fat and vitamin B12
endoscopy and biopsy
334
How do you manage tropical sprue?
tetracycline and folic acid
335
What is whipple's disease caused by?
tropheryma whippelii (gram positive)
336
What is the epidemiology of whipple's disease?
common in middle aged white males in europe
337
What are the signs and symptoms of whipple's disease?
arthralgia
ab pain
weight loss
diarrhoea/steatorrhoea
fever
sweats
chronic cough
endocarditis potentially as well as lypmhadenopathy
338
how do you diagnose whipple's disease?
PAS macrophages are present ( periodic acid-schiff)
jejunal biopsy
bacteria sen on electronic microscopy
339
How do you treat whipple's disease?
antibiotics across BBBIV
IV ceftriaxone then co-trimoxazloe
340
What is meckel's diverticulum
remnant vitleine duct- the proximal part of the viteline duct ( yolk stalk) fails to regress and involute
341
Where is meckel's diverticulum found?
anti mesenteric border of the ileum (found at distal part)
342
What are the signs and symptoms of meckel's diverticulum?
usually symptomless
Peptic ulcers can form - contains gastric mucosa which secretes HCL.
can have intestinal obstruction
diverticulitis can also occur
343
How do you manage and diagnose meckels?
radio nucleotide scan
surgical excision ( laparoscopically)
344
What are the complications of meckels?
Bleeds
ulcerate
obstruction
malignant change
345
what is the rule of 2 for meckle's?
2 feet from ileiocacecal junction
2% of population have it
346
What are the causes of Bacterial overgrowth
Spontaneous in the elderly
stricture or diverticulum - structural abnormality in the small bowel
post op bind loops
PPI and diabetes mellitus are Risk factors
347
How do you diagnose bacterial overgrowth?
Hydrogen breadth test
348
How do you manage bacterial overgrowth?
Resection of strucutre
metronidazole or a tetracycline
349
What happens to peristalsis in small bowel obstruction?
Disrupted
350
What type of abdominal pain is felt in small bowel obstruction?
colicky pain
351
What are the causes of bowel obstruction?
Mechanical obstruction causes
Small bowell:
Adhesions ( outside of bowel)- congenital,from post op or peritonitis
Hernias ( outside of bowel)
Large bowel:
colon cancer ( inside of bowel)
constipation (inside of bowel)
diverticular stricture- usually incomplete
Volvulus( sigmoid and caecal)
rarer causes; crohn's stricture (usually incomplete) , Gallstone ileus and
foreign body or bolus obstruction or intussusception- a segment of bowel wall becomes telescoped into the segment distal to it ( common in children)
352
What are the signs and symptoms of bowel obstruction?
vomiting- with nausea and anorexia
Constipation
colic - occurs early
abdominal distention- increases as obstruction increases with tinkling bowel sounds- sounds may be absent in examination or sound like 'water lapping against a boat'
dehydration
visible peristalsis
relative lack of abdominal tenderness
353
What is a volvulus?
type of bowel obstruction where bowel twists causing an obstruction
354
What type of obstruction is a volvulus?
Closed loop
355
Discuss how the two main types of volvulus occurs.
sigmoid vovlulus- when the bowel twists on its mesentery
caecal- when ileo caecal valve which is still competent cannot move backwards to relieve the pressure- causes distention of caecum lead to obstruction
356
What are the main differences between gastric outlet ,small and large bowel obstruction?
Gastric outlet obstruction- semi digested food is vomited with no bile
Small bowel ( compared to large bowel obstruction mainly)
vomiting occurs more early
copious bile stained fluid present in vomiting
pain is more prominent
less distention
Large bowel
thicker, brown, foul smelling vomitus (faeculent)
pain is more constant
symptoms more gradual
absolute constipation a sign of distal obstruction
357
What is the difference between incomplete and complete obstruction?
incomplete:
clinical features in incomplete are less clear
vomiting is intermittent and bowel habit is erratic
hypertrophy of the bowel wall muscle occurs in chronic cases - leads to far more prominent colicky pain than with complete obstruction
358
What occurs with strangulated bowel obstruction?
1. blood supply is compromised
2. sharper, more localised and constant pain
3. fever and increased white blood cell count
359
What is the main sign of strangulated bowel obstruction?
peritonism
360
What happens if the ileo caecal valve becomes incompetent?
small bowel distends which delays symptoms
361
What is paralytic ileus?
adynamic bowel due to absence of normal peristalsis
362
What are the signs and symptoms of paralytic ileus?
pain and high pitched sounds less common in comparison to bowel obstruction
363
what are the risk factors of paralytic ileus?
abdominal surgery
pancreatitis (or any localised peritonitis)
hypokalaemia
peritoneal sepsis
diabetic keto acidosis
364
How do you treat paralytic ileus
Drip and suck- NGT and IV fluids to correct electrolyte imbalance while awaiting restoration of peristalsis
365
How do you diagnose bowel obstruction
AXR
distended small bowel- tend to lie in a central position and have valvulae coniventes
distended large bowel- tend to lie in its anatomical position and has haustra coli
sigmoid volvulus- coffee bean signs
erect EXR- assess for perforation- air under diaphragm
CT usually used after AXR to confirm diagnosis and look for a cause ( may show dilated, fluid filled bowel and a transition zone at the site of obstruction)
366
How do you manage bowel obstruction
conservative:
Drip and suck - naso gastro tube and IV fluid to rehydrate and correct electrolyte imbalance as well as decompress stomach
specific management:
strangulation needs emergency surgery
large bowel needs surgery
small bowel and ileus only require conservative management
closed loop may need surgery or decompression
sigmoid volvulus- needs flatus tube or sigmoidoscopy
peritonitis- emergency laparotomy
367
what is pseudo obstruction?
adynamic bowel obstruction- acute dilation of colon occurs but no obstruction present
368
what is acute colonic form of pseudo obstruction called?
ogilvie's syndrome
369
what are the risk factors of pseudo obstruction?
surgery ( hip replacement and CABG)
pneumonia
elderly
370
How do you diagnose ogilvie's syndrome?
AXR and CT
371
How do you manage ogilvie's syndrome?
colonoscopy allows decompression - if causing pain or respiratory compromise
exclude mechanical causes
372
What is a diverticulum?
outpouching of the gut wall usually at sites of entry of perforating arteries
373
what is the difference between:
1. diverticulosis
2. diverticulitis
3. diverticular colitis
1. indicates presence of diverticular
2. implies diverticular is inflamed
3. crescentic inflammation on the folds in areas of diverticulosis
374
what is the difference between diverticular disease and diverticulosis?
diverticular disease implies the diverticulosis is symptomatic
375
where is the main place for diverticular diesease in the colon?
sigmoid colon
376
What is the cause of diverticular disease?
low dietary fibre causes high intraluminal pressures forcing the mucosa to herniate through the walls
377
What is the difference between a false and true diverticulum?
true- all three layers of colon wall are effected
false- only mucosa and sub mucosa are effected
378
What are the signs and symptoms of diverticular disease?
majority of diverticular disease is asymptomatic
symptoms:
altered bowel habit: constipation and diarrhoea
LLQ pain - relieved by defecation, nausea and flatulence
occasional episodes of blood/mucous PR
379
How do you diagnose diverticular disease?
mainly incidental via colonoscopy then barium enema exam
sometimes CT
380
how do you manage diverticular disease?
well balanced fibre diet
antispasmodics
might need resection
381
what are the signs and symptoms of diverticulitis?
severe left iliac fossa pain
fever
constipation
tachycardia
tender colon
altered bowel habits
382
Where is acute diverticulitis normally found?
sigmoid colon
383
How do you diagnose acute diverticulitis?
CT is main way - shows colonic wall thickening
Blood tests- raised WCC,CRP/ESR
AXR may identify obstruction or free air (perforation)
colonoscopy increases risk of perforation
384
How do you manage acute diverticulitis?
Bowel rest
mild forms can give fluids
IV antibiotics , NBM
if Abscess form than percutaneous drainage
385
What are the main complications of diverticular disease?
ii. how do they present?
Perforation- Ileus, peritonitis and shock
Haemorrhage- sudden and painless can be massive.
fistula- either enterocolic, colovaginal (causes discharge) or colovesical ( causes pneumatruria)
abcesss-swinging fever, raised WCC and boggy rectal mass on PR
strictures- constipation
386
what is hartmanns procedure?
surgical resection of the recto sigmoid colon and formation of an end colostomy
387
where are the 2 surgical operations used for diverticular disease?
hartmanns procedure
primary resection/anastomosis
both used mainly used for complicated diverticulitis
388
What is the main site of ischaemic colitis ?
splenic flexure- where marginal artery of drummed connects IMA and SMA
leads to occulsion of IMA
389
what are the signs and symptoms of ischaemic colitis?
LLQ pain
passage of bright red blood per rectum
sometimes diarrhoea
shock
evidence of PVD
390
How do you diagnose lschaemic colitis?
colonoscopy(first use) and biopsy show epithelial cell apoptosis
AXR -shows thumb-printing at splenic flexure
Barium enema
may show signs of cardiovascular shock
CT - excludes perforation
mesenteric angiography
391
How do you manage ischaemic colitis?
fluid replacement and antibiotics
if gangenous Ischaemic colitis then resuscitation followed by resection of the affected bowel and soma formation
392
what are the main causes of colitis?
Infective colitis
UC
crohn's colitis
ischameic colitis
393
what are the signs and symptoms of colitis?
Diarrhoea + blood
abdominal cramps
dehydration
sepsis
wt loss, anaemia
394
How do you diagnose colitis?
Plain X-ray
Sigmoidoscopy + biopsy
stool cultures
barium enema
first sigmoid
second colonoscopy
395
what is microscopic colitis associated with?
watery diarrhoea
396
what is the main way to diagnose microscopic colitis?
biopsy
397
what is colonic angiodysplasia?
Submucosal lakes of blood
398
where is angiodysplasia usually found?
right side of colon
399
what are the signs and symptoms of angiodysplasia?
sometimes blood loss PR
signs of anaemia
400
How do you diagnose colonic angiodysplasia?
Angiography
| Colonoscopy
401
How do you manage colonic angiodysplasia?
embolisation
endoscopic ablation
surgical resection
402
what is a colonic polyp
an abnormal growth of tissue projecting from the the colonic mucosa
403
are polyps malignant?
can be depends on the type
hyperplastic
inflammatory
hamartomatous - large and stalked include: juvenile syndrome and peutz-jeghers syndrome
neoplastic
404
what is the main type of colonic polyps?
adenomas
405
all adenomas are dysplastic true or false?
true
406
What are the risks of adenomas?
they are premalignant and so can form adenocarcinomas of the colon and rectum
407
how are adenomas removed?
endoscopically or surgically
408
what are the main types of adenoma polyps of the colon?
Tubullovillous
tubular
villous
Sessile serated- separate pathway for formation
flat adenomas
409
How do you diagnose and manage
colonoscopy and polypectomy
chromoscopy uses dye to help detect
410
what are the signs and symptoms of colorectal polyps
bleeding PR
similar to colorectal cancer
411
what is the main type of carcinoma which causes colorectal carcinoma?
adenocarcinoma
412
what are the risk factors of colorectal carcinoma?
1. neoplastic polyps ( adenomas)
2. IBD
3. genetic predisposition:
1. Familial adenomatous polyposis (FAP)- 100% penetrance mutation of APC gene autosomal dominant on chromosome 5. Early onset
2. Hereditary nonpolyposis colorectal cancer (HNPCC)- autosomal dominance mutation of DNA mismatch repair gene. Late onset
4. smoking
5. alcohol
6. low fibre and increased red meat in take
7. over age of 60 and male
413
what are the signs and symptoms of colorectal cancer?
depends on site- most are on left side or rectum
left sided: bleeding/mucus PR and altered bowel habit- probs cause of obstruction
tenesmus- rectal
hard rectal mass
Right sided: weight loss, anaemia ,abdominal pain- less likely from obstruction
General: abdominal mass, perforation haemorrhage and fistula
414
what is the most simple staging for colorectal cancer?
ii. how is it staged?
duke stagings
dukes A: confined by muscularis propria
dukes B: through muscularis propria
dukes C: metastatic to lymph nodes
dukes D: distant mets
415
whats the difference between the two main types of inherited colorectal carcinomas?
HNPCC is late onset and mainly forms right sided tumours
it also has less than 100 polyps
has an inflammatory response
mucinous tumours
FAP is early onset and forms tumours throughout
has more than 100 polyps
has no inflammatory response.
adenocarcinomas
416
How does colorectal cancer spread?
Direct spread
Lymphatic spread
blood spread ( liver lung bone)
transcoelomic spread ( rare)
417
How do you diagnose CRC?
bowel screening programme - offered screening in via giving stool sample every 2 years- if positive offered colonoscopy
red flag symptoms- SOPD or straight to endoscopy
Bloods- FBC for microcytic anaemia and faecal occult blood(FOB) (part of screening).
CT colonoscopy
418
What happens in TNM staging?
T1- invading submucosa
T2- invading muscularis propria
T3- invading suberos and beyong
T4- invasion of adjacent structures
419
how do you stage colorectal carcinoma?
chest abdominal and pelvic CT
MRI for rectal cancers
420
How do you manage CRC?
Surgery: Main Laparoscopic
right hemicolectomy- caecal ascending or proximal transverse colon
left hemicolectomy- distal transverse or descending
sigmoid colectomy- sigmoid
anterior resection- low sigmoid/hight rectum
AP- rectum
Harmann's preocedure in emergency bowel obstruction
stenting decreases need for colostomy and can be used for palliative care
radiotherapy: pallation - post op only used for rectal tumours with high local recurrence
chemotherapy: higher stages of tumour palliation
can be used with cancer resection in advanced management
HIPEC for mesothelioma and peritoneal metastasis
monoclonal antibodies: cetuximab and pitumumab help too used in stage 4
421
which is more common- primary or secondary tumours of the small bowel?
secondary tumours
422
what are the 3 main types of primary tumours?
lymphomas
carcinoid tumours
carcinomas
423
where is the most commonest site for a carcinoid tumour of the small bowel?
appendix
424
what is IBS?
irritable bowel syndrome- common functional bowel disorder. No organic cause can be found.
425
what is the epidemiology of IBS?
under the age of 45
female ( 2:1)
have a family history of IBS
mental health issues- anxiety and depression, psychological stress and trauma
post infectious IBS
426
what is the pathophysiology of IBS?
disturbed GI motility
visceral perception
microbial dysbiosis
427
what are the signs and symptoms of IBS?
recurring abdominal pain for at least three days a week and is chronic ( more than 3 months)
(rome criteria III)
associated with at least 2 of these factors:
pain relieved by defection
altered stool form ( bristol chart)
altered bowel frequency
other symptoms
incomplete emptying of bladder
nocturia ( passing urine at night)
poor sleep
dyspareunia (pain after intercourse)
mucus PR
abdominal bloating
sign- can have abdominal tenderness
428
what are the main subtypes of IBS?
IBS-C- where more than 25% of stool is hard and lumpy( or less than 25% is watery)
IBS-D - where more than 25% of stools are watery( or less than 25% are hard and lumpy)
IBS-M where both hard lumpy and watery stools make up more than 25% of stools
unsubtyped IBS
429
How do you diagnose IBS?
first through symptoms
then do history to see if symptoms match with IBS
Do FBC to exclude anemia
CRP/ESR,TSH and TTG
can do selective AXR
can do serum CA to exclude ovarian cancer
lower GI testing if FH of CRC
430
what symptoms suggest that it might not be IBS?
```
age > 50
short duration of symptoms
woken from sleep to run to toilet
rectal bleeding
weight loss
anaemia
FH of colorectal cancer
```
abnormal CRP and ESR
431
How do you manage IBS?
if no positive result from test then in the clear!
Validate their concerns
Reassure- everything is groovy
Inform- ts chronic
IBS-C
diet- adequate water and fibre intake ( avoid insoluble fibre increases bloating) and more exercise
simple laxatives- polyethene glycol or lactulose( lactulose can ferment and cause bloating)
antispasmoidics- may not work well ( colofac and spasmonal) stops bloating
can also use 5-HT4 receptor agonists (prucalopride)
IBD- avoid alcohol and caffeine and reduce dietary fibre
can use antispasmodics to reduce bloating
use bulking agent and loperamide ( antidiarrhoeal agent)
General-
antidepressants ( tricyclics)- much lower doses than for depression
psychological therapy- CBT, psychotherapy and hypnotherapy
432
what is a haemorrhoid?
enlarged vascular cushions in the lower rectum and anal canal
433
what are anal cushions
discontinuous spongey vascular tissue which are involved in anal cushion
434
what are the causes of haemorrhoids?
constipation with prolonged straining
CCF
pregnancy
portal hypertension
pelvic tumour
435
what are the signs and symptoms of haemorrhoids?
bright red rectal bleeding sometimes found on stools but mainly found on paper
pruitius ani ( itch bottom)
should have no change in bowel habit or weight
maceration of the perianal skin
436
viewed from the lithotomy position where are the three anal cushions?
3 o clock
7 o clock
11 o clock
437
what type of haemorrhoids are there?
external- origin below dentate line
internal- origin above dentate line
mixed- origin above and below
438
what are the classification of haemorrhoids?
1st degree- remain in the rectum
2nd- prolapse through the anus on defecation but spontaneously reduce
3rd- 2nd degree but require digital reduction
4th- remain persistently prolapsed
439
How do you diagnose haemorrhoids?
PR exam- internal haemorrhoids are not palpable
rigid sigmoidoscopy
proctoscopy
flexible sigmoid over age of 50
440
How do you manage haemorrhoids?
Increase fruit and fibre topical analgesic and stool softener
Sclerosation therapy- 2ml of 5% phenol in almond oil is injected into the pile above the dentate line
rubber band ligation- cheap
open haemorrhoidectomy
stapled haemorrhoidectomy- for prolapsing haemorrhoids- less pain but higher recurrence
HALO- uses Doppler US to identify and ligate feeding arteries to haemorrhoids- can replace surgery. use general or spinal anaesthesia
441
what are the two types of rectal prolapse?
partial- mucosa (anterior mucosal prolapse)
complete -all layers (full thickness) more common
442
what are the signs and symptoms of a rectal prolapse?
protruding mass from anus especially during defecation
bleeding and passing mucus per rectum
- can be incontinent
poor anal tone
can reduce spontaneously
443
How do you treat rectal prolapse?
complete prolapse
most patients to frail for surgery -use bulking agents and education for manual reduction
delorme's procedure
perineal rectopexy
abdominal rectopexy
anterior resection
incomplete
children- give dietary advice and treatment of constipation
adults- treatment similar to that of haemorrhoids
444
what is a fistula-in-ano
anal fissure - tear in the squamous lining of the lower anal canal
445
where are anal fissures found normally?
90% posteriorly
| 10% anterior- follow parturition
446
what are the causes of anal fissuers?
Hard stool main cause
rare causes: herpes and crohn's, UC and anal cancer
447
what are the signs and symptoms of anal fissures?
severe anal pain
pain lasts for up to 30 mins after defecation
can have bright rectal bleeding
448
How do you manage anal fissures?
Dietary fibre, fluids and stool softener and dietary advice
lidocaine ointment and 0.3% GTN ointment or diltiazem 2%
2nd line botox injection
surgery- lateral sphyncterotomy
449
what is a fistula-in-ano?
abnormal communication between the skin and anal canal/rectum
450
what are the causes of fistula-in ano?
perinanal sepsis
abscess- due to delay or inadequate treatment of an abscess , fistulas form
CD
TB
diverticular disease
rectal carcinoma
451
what is goodsall's rule?
determines path of fistula's track
anterior- track is in a straight line
posterior- internal opening is always at a 6 o clock position track is tortuous
452
what are the signs and symptoms of an anal fistula?
abscess and visible external opening (anorectal ulcer)
could have underlying condition (crohns)
453
how do you diagnose an anal fistula?
exam under anaesthetic of anorectum
rigid sigmoidoscopy and proctoscopy
or flexible sigmoidoscopy
MRI
454
How do you manage an anal fistula?
"laying open"
stage 1. Fistulotomy- opening up of fistula and allow to heal by secondary intention
stage 2. seton drain- done if anal sphincter involved
455
what are the causes of anorectal abscesses?
gut organisms or idiopathic
456
what are the diseases associated with abscesses?
crohns
cancer
fistulas
457
what is pruritus ani?
itchy ass
458
how do you manage pruritus ani?
don't scratch
perianal hygiene
avoid foods which loosen stool
soothing ointment/topical corticosteroids
459
what are common causes of RUQ pain?
Biliary colic and cholecystitis
Hepatomegaly
hepatitis
duodenal ulcer
appendicitis
460
what are common causes of LUQ pain?
gastritis
ruptured spleen
pancreatitis
gastric ulcer
perforated colon
461
what are common causes of epigastric pain?
pancreatitis
peptic ulcer
acute cholecystitis
perforated oesophagus
myocardial ischaemia
462
what are common causes of RLQ pain?
appendicitis
renal stone
meckels diverticulititis
strangulated hernia
crohns
perforated caecum
463
what are causes of LLQ pain?
sigmoid diverticulitits
ruptured ectopic pregnancy
IBD ( both types)
perforated colon
salpingitis
464
what are common causes of umbililcal pain?
intestinal obstruction
acute pancreattitis
early appendicititis
salpingitis
465
what are the common causes of acute abdominal pain?
Non specific abdominal pain
acute appendicitis
Gall bladder diseases
rare causes: intestinal obstruction, peforated ulcer, renal colic,UTI and gynaecological disorder
466
what are the signs and symptoms of acute abdomen?
Tachycardia
shock
abdomen pain:
sudden onset pain suggests- perforation, rupture, torsion, acute pancreatitis or infarction
back pain: pancreatitis, rupture of aortic aneurysms or renal tract disease
vomiting- associated with all abdomen pain but if persistent suggest obstructive lesion of the gut. what type of colour does it have?
bowel habit?- any change should be taken down
cullen's sign (brusing)- pancreatitis
bowel sounds: no sound then peritonitis or ileus
tinkling sound- obstruction
pulsatile mass-aortic aneurysm
467
what are the specific symptoms of peritonitis?
prostration
shock
lying still
abdominal rigidity and guarding
no bowel sounds
468
what are the main specific symptoms of a ruptured organ?
shock
abdominal swelling
469
How do you diagnose acute abdomen?
Bloods: FBC, WCC, serum amylase (five times above=acute pancreatitis),CRP,LFT and Lactate (mesenteric ischaemia?)
urine dipstick and and serum hCG to exclude pregnancy
Erect chest X ray - first line excludes pneumonia . detects air under diaphragm caused by perforation
AXR- may show rigler's sign -pneumoperitoneum
CT- gold standard- spiral CT very accurate
US useful for acute cholangitis, cholecystitis and AA. useful in Kids and women with pelvic pain
470
How do you manage acute abdomen?
Initial management: ABC
urinalysis
give oxygen and fluids (resuscitate)
treat pain- analgesia
antibiotics
urgent surgery for: ectopic pregnancy, bowel ischaemia and peritonitis. Laparotomy
don't go to surgery if pancreatitis or DKA and anyone that is non trauma
471
what is the main cause of appendicitis?
lumen of appendix becomes obstructed with faecolith
472
what happens if the appendix isn't removed when inflammation occurs?
potentially leads to gangrene with perforation which can then cause general peritonitis
473
what are the signs and symptoms of acute appendicitis?
poorly localised periumbilical pain
pain also spreads to the RIF
tachycardia
fever
guarding- due to localised peritonitis
tender mass in RIF- particularly over mc Burney's point
anorexia
Rovsing's sign ( pain greater in RIF when LIF is pressed)
474
how do you investigate acute appendicitis?
bloods: raised WCC and ESR and CRP
imaging: not always used
US is helpful but appendix is not alway visualised
CT is very accurate and so only used if not certain
475
How do you manage acute appendicitis?
Antibiotics and IV fluid - conservative treatment mainly if appendix mass is present. formed when inflamed and covered by omentum. usually disappears
laparoscopic surgery removes appendix
476
What are the causes of mesenteric ischaemia?
thrombotic or embolic blockage of SMA
477
what are the signs and symptoms of mesenteric ischamia?
Acute abdomen symptoms
history of AF or vascular disease
478
how do you diagnose mesenteric ischaemia?
same with acute abdomen
mesenteric angiography
479
How do you manage MI?
Resuscitation and stabilise
| Emergency laparotomy: bowel resection and revascularisation
480
What is a hernia?
An abnormal protrusion of a cavity's contents through a weakness in the wall of the cavity
481
what are the causes of hernias?
anatomical- openings in cavity
ingeirted collagen disorders
sites where surgical incisions are made
482
How are hernias classified?
reducible- can be pushed back
irreducible- cannot be pushed back
obstructed- hernia blocks bowel contents
strangulated- hernia causes ischaemia
incarceration: hernia stuck down by adhesion
483
What type of abdominal hernias are there?
Inguinal- most common type
femoral- shows as a mass in the upper medial thigh. more common in women. more likely to be irreducible or strangulated
epigastric - above the umbilicus
paraumbilcal- just above or below the umbilicus.
spigelian- occur through the linea semilunaris at the lateral edge of the rectus.
lumbar hernia- occur through the inferior or superior lumbar triangles in the Post ab wall
incisional hernias- occur after breakdown of muscle closure after surgery
richter's
maydl's
littres
sliding
paediatric hernias ( include umbilical and indirect inguinal)
femoral - pear shaped no symptoms
484
what types of inguinal hernias are there?
indirect- more common
direct- push through hesselbach's triangle
485
what are the anatomical relations of the hesselbach's triangle?
medial to the epigastric vessels and lateral to the rectus abdominus
486
what is the epidemiology of inguinal hernias?
more frequent in males
right sided hernias more common
487
what are the risk factors of adominal hernias?
obesity, heavy lifting , pregnancy and congenital defects in abdominal wall, ascites and chronic cough
constipation
488
How do you identify the inguinal internal and external rings which are the openings to its canal?
internal ring- mid point of the inguinal ligament. just above femoral pulse
external ring - just superior and medial to the pubic tubercle
489
what age do congenital umbilical hernias usually resolve by?
3
490
what are the anterior, medial, lateral and posterior boundaries of the femoral canal?
anterior- inguinal ligament
medial- lacunar ligament
lateral- femoral vein
posterior- pectinate ligament
491
what are the signs and symptoms of hernias?
abdominal mass is present
abdominal pain- frequent with paraumbilcal hernia due to strangulation
strangulated or incarcerated causes symptoms
492
How do you diagnose hernias?
anatomical position
for inguinal hernia:
feel mass- make sure not scrotum lumo
get patient to cough- exaggerates it
make patient stand- then ask to cough if the hernia while placing hand on internal inguinal ring. Direct hernia will return. Indirect will not.
493
how do you manage abdominal hernias?
weight loss and stop smoking.
surgery either open or laparoscopic repair
tell patient they might return
494
what is step 1 of MUST?
BMI above 20= 0
18.5-20= 1
less than 18.5=2
495
what is step 2 of MUST?
```
weight loss score
(unexplained weight loss in past 3-6 months)
less than 5 percent = 0
5- 10 percent = 1
greater than 10 percent = 2
```
496
what is step 3 of MUST?
if patient is acutely ill AND likely to be no nutritional intake for >5days = 2 points
497
what is Step 4?
add scores from step 1, 2 and 3 to calculate overall risk of malnutrition
0 = low risk
1 = medium risk
2+ = high risk
498
how do you calculate BMI?
mass (kg)/
| height^2(m)
499
what is the 4 step pyramid of nutritional support?
food
oral nutritional supplements
enteral nutrition
parenteral nutrition
500
what is refeeding syndrome?
occurs when previously malnourished are fed with high carbohydate loads
this causes a rapid decline in electrolytes and an increase in extracellular volume which results in organ dysfunction
501
what are the main metabolic features of refeeding syndrome?
```
hypokalaemia
hypophosphataemia
hypomagnesaemia
altered glucose metabolism
fluid overload
```
502
what are the physiological features of refeeding syndrome?
```
arrhythmias
altered level of consciousness
seizures
respiratory failure
cardiovascular collapse
death
```
503
how do you prevent refeeding syndrome in moderate risk patients?
how do you prevent refeeding syndrome in moderate risk patients?
504
what must you do to prevent refeeding syndrome in high risk patients?
rehydrate carefully and supplement potassium, magnesium, phosphate, calcium, thiamine and vit B
start feeding at 5-10kcal/kg/day
505
what part of the hypothalamus seems to be associated with decreased and increased energy expenditure?
1. decrease- lateral
| 2. increased ventromedial
506
what is ghrelin?
a gut hunger signal secreted from oxyntic cells in stomach
507
what is scurvy?
nutrintional disorder due to lack of vitamin C
508
what is the patient like associated with scurvy?
pregnant
poor
odd diet
509
what are the signs and symptoms of scurvy?
listlessness anorexia and cahexic
gingivitis and halitosis
bleeding from gums and nose
muscle pain
oedema
510
how do you manage scurvy?
dietary education
ascorbic acid
511
what is pellagra?
lack of nicotinic acid big in China and Africa
512
what are the symptoms of pellagra?
1. diarrhoea, dementia and dermatitis (classic)
neuropathy, depression insomnia and fits
513
how do you manage pellagra?
electrolyte replacement and nicotinamide added
514
what are the 6 major classes of antiemetic drugs?
```
5HT3 receptor antagonists
Muscarinic ACh receptor antagonists
Histamine H1 receptor antagonists
Dopamine receptor antagonists
NK1 receptor antagonists
Cannabinoid receptor agonists
```
515
what are the clinical features of vitamin B1 defiency?
Wernicke's encephalopathy: Encephalopathy,
oculomotor dysfunction - lateral rectal palsy
gait ataxia
