GI Conditions Flashcards

Question

What is the clinical presentation of cirrhosis

Answer 1

Abdominal distension - secondary to ascites from portal hypertension also due to reduced hepatic excretion of conjugated bilirubin Jaundice and pruritis (itchy skin)- reduced hepatic excretion of conjugated bilirubin Encephalopothy- high levels of ammonia = confusion, altered glasgow coma scale, asterixis/liver flap Blood in vomit- haematemesis, malaena- GI bleed from varices due to PH caused liver cirrhosis Hand and Nails- leukonychia (white line on nails) due to hypoalbuminaemia, plamar erythma, clubbing, dupuytren contracture (curled fingers from alcholol related liver disease) Spider naevi- fill from centre gynocomastia Hepatomegaly and splenomegaly A to J Abdominal distention/ascites, Bile stasis, Calcium and Vitamin D deficiencies, En- cephalopathy, Factors deficiency, and Gastroesophageal varices, A to J of Liver Failure ⇒ asterixis, bruising, clubbing, dupuytren’s contracture, erythema (palmar), fetor hepaticus (bad breath), gynaecomastia, hepatomegaly, itching, jaundice

Answer 2

Ascites Splenomegaly Caput medusae Oesophageal and rectal varices

Answer 3

-Transient elastography 'Fibroscan' to measure liver stiffness or Acoustic radiation force impulse imaging. AS NON INVASIVE if non alcoholic fatty liver disease: use liver fibrosis score to screen if need further testing - Liver Biopsy*→ most specific and sensitive test for diagnosis of cirrhosis - Upper GI Endoscopy → check for varices (swelling of veins in oesophagus and rectum due to portal hypertension) in patient’s with new diagnosis of cirrhosis - Liver Ultrasound (and AFP) every 6 months to check for hepatocellular cancer - Bloods - LFTs → AST & ALT levels increase with hepatocellular damage. Normally ALT>AST except for alcohol-related liver disease. (AST- a shot too many) - Serum Albumin → reduced. Marker of hepatic synthetic dysfunction. - PT → prolonged. Marker of hepatic synthetic dysfunction. - Serum Sodium → reduced. Common finding in cirrhotic patients with ascites. Hypervolaemic Hyponatraemia. Diagnose SBP through paracentesis - Child-Pugh Score (severity of liver cirrhosis)- higher the score the more likely they have portal hypertension, oesophageal varices and haematemisis based on ABCDE albumin bilirubin clotting PT time Distension (ascites) Encephalopothy

Answer 4

Child-Pugh classification system. based on bilirubin, albumin, PT, encephalopathy and ascites A= less than 7 B= 7-9 C= higher than 9 MELD (model for end stage liver disease)- higher the score the higher the severity

Answer 5

if from ALD- stop alcohol, no cure for Hep b and c infection TREAT SYMPTOMS for encephalopathy- lactulose to reduce ammonia absorption. Rifaximin as secondary prophylaxis as stops recurrence Ascites- sodium restriction, diuretic terapy with spirinolactone. paracentesis to drain spontaneous bacterial peritonitis (SBP)- prohylactic ABs ciprofloxacin or norfloxacin surgical- TIPS (tranjugular intrahepatic portosystemic shunt ) to reduce portal hypertension and reduces oesophageal varices risk. - if already have oesophageal varisces then give terlipressin and IV antibiotics, propanolol as prophylaxis and blood tranfusion if bleeding severe and Hb below 7 liver transplant - if develop hepatocellular carcinoma

Answer 6

ascites gastro-oesophageal varices which may rupture Varices can lead to caput medusae hepatocellular carcinoma bleeding and thombosis spontaneous bacterial peritonitis prognosis- median survival 10 years, depends on stage tho

Answer 7

-Autoimmune disorder characterized by an intestinal hypersensitivity to gluten, causing chronic intestinal malabsorption - Triggered by Gliadin (protein in wheat) - F more, any age - Other autoimmune disorders

Answer 8

Diarrhoea- steatorrhea (pale, greasy floaty, bad smelling) from malabsorption Sudden weight loss Bloating Abdonimal Pain Anaemia - malabsorption symptoms IgA delficiency- autoimmune attacks dermatitis Herpetiformis- really itchy papulovesicular lesions on extensor surfcaes like elbows and knees FHx- osteopenias/osteoporosis (malabsorption of vit D), Fatigue, failure to thrive (delayed puberty)

Answer 9

SEROLOGY - IgA-tTG (tissue transglutimase) antibodies - will be elevated anti-endomysial antibodies (EMA) and anti-gliadin antibodies (DGP deaminated gliadin peptide) also elevated. Do EMA if tTG unavailable and DGP if IgA deficient FBC- low Hb, mcrocytic hypochromic red cells. Skin biopsy- if any lesions look like dermatitis herpetiformis. small bowel endoscopy and histology if biopsy anything- GOLD STANDARD TO CONFIRM. scalloping due to villois atrophy, crypt hyperplasia. Histology will reveal intra epithelil lymphocytes, villous atrophy and crypt hyperplaia - have to be eating a gluten diet at the time blood smear- look for target cells and howell jolly bodies as coeliac can cause hyposplenism

Answer 10

Gluten free diet- abstain from wheat, rye, barley, (oats may grow along side so to avoid) vitamin and mineral supplements pneumococcal vaccine- functional hyposplenism so risk of pneumococcal sepsis

Answer 11

osteoporosis/osteopenia - lack of vit D Dermaitits herpetiformis malignancy- enteropathy-associated T cell lymphoma. interepithelial T lymphocytes become malignant iron/folate/b12 deficiency prognosis- gluten free die is resolution for most, less than 1% develop refractory coeliac disease

Answer 12

Cancers- usually adenocarcinoma from epithelium cells. 60% rectum and sigmoid, 30% decending. Most sporadic 95%, 5% hereditary non-polyposis colorectal carcinoma 65-74 years old RF- age, FHx, familial adenomatous palyposis, associated conditions- IBD and polyps, Alcohol, T2D, Obesity, Lynch syndrome

Answer 13

Rectal bleeding- mixed in stool Change in bowel habit- inc frequency or loose stool Iron Def Anaemia- (fatigue, SOB, pallor) Tenesmus- feeling of incomplete emptying FLAWS: fever, lethargy, anorexia, weight loss, sweats Hepatomegaly- if liver met Rectal mass- found on DRE

Answer 14

RIGHT SIDED:malaena, iron deficiency anemia, diarrhoea LEFT SIDED_ change in bowel habit, blood streaked stool mixed in, colicky abdo pain RECTAL-hamatochezia (bright red blood in stool), rectal pain, tenesmus, flatulence, fecal incontinence

Answer 15

Colonoscopy + Biopsy -> to diagnose, must take laxatives day before FBC- microcytic anaemia, low ferritin, LFTs look for mets CT CAP- look for mets. Dukes staging- A tumour limited to mucosa), B (tumour invading bowl wall), C (lymph node mets), D (distant mets). Barium enema- apple core lesion from stricture due to mass lesion. DRE- all with lower GI bleeding or red flags should have FIT test- Tumoru markers- CEA monitor disease progression Any patient over 60 with iron def anaemia or a bowel havit change should be referred for bowel cancer 2 week wait. If have symptoms of possible bowel caner but dont meet 2WW standard then FIT

Answer 16

Surgical excision + adjuvant or neoadjuvant chemo/radiotherapy Anastomotic leak- complication of bowel resection surgery 5-7 days post operation.will present as diffuse abdo tenderness, guarding, hypotensive and tachy

Answer 17

Complications- bone marrow suppression from chemo GI toxicity from chemo side effects of immunotherapy drugs metastases to liver lung, bone, brain Prognosis- half have mets at diagnosis

Answer 18

Infrequent passage of stool, 3 or less per week

Answer 19

No faeces or flatus

Answer 20

Primary Constipation- due to poor diet- lack of fibre, dehydration and insufficient exercise Secondary Constipation- colorectal cancer, diveticulosis, haemorrhoids, bowel obtruction, hypothyroidism, IBS, opiods Risk- females over 65, low fibre intake, sedentary lifestyle, medicines- opiates, CCBs, antipsychotics

Answer 21

infrequent stools less than 3 a week difficult defecation exessive straining Tenesmus- incomplete hard stools confusion if impactation Can cause outflow obstruction and cause episodes of urinary retention in pt with enlarged prostate Bristol stool chart- goes up to 7 Constipation is typically type 1 or 2 - Type 1 - hard lumps, like nuts - Type 2 - sausage-shaped, but lumpy Rome IV Diagnostic Criteria for functional constipation 2 of the symptoms in 25% or more of defecations in the last 12 weeks with symptoms at least 6 months ago symptoms: <3 stools a week hard or lumpy sensation of anorectal obstruction/block manual aid to evacuate straining tenesmus

Answer 22

Anal Manometry- for evaluation of constipation or functional anorectal pain FBC- if think secondary cause like iron deficiency anaemia TFT- hypothyroidism AXR- rectal mass or faecal impactation

Answer 23

CHildren- delayed meconium over 48 hours severe abdominal distension blood in stool constipated when less than 1 month old FHx of constipation related disorders like Hirschsprung Bilious vomiting fever failure to thrive congenital abnormalities Adults: FHx- colorectal cancer, IBD Iron deficiency anaemia Blood in stool significant weight loss sudden onset of new change in bowel habit over 50 yrs and no cancer screening Palpable mass reduced stool amount rectal prolapse persistent constipation

Answer 24

Lifestyle-high fibre diet, increased fluid intake, exercise Bulk laxatives, stool softeners Osmotic laxative like lactulose stimulant laxative like senna if lactulose doesnt work Prunes opioid induced- review opioid and give laxative. plus lifestyle and diet not opioid- 1st - treatment of underlying cause, diet and lifestyle and to consider laxative 2nd- osmotic and or stimulant laxative with diet changes If faecal impaction- evacuation measures

Answer 25

Complication- anal fissure, haemorrhoids, faecal impaction Prognosis- medical therapy usually effective

Answer 26

Any clinical state causd by symptoms pertaining to colonic diverticula which are outpouchings of the colonic mucosa DiverticuLOSIS- presense of diverticula in colon, no symptoms and dont need treatment. can have blood in stools and can lead to diverticulitis Diverticular DISEASE- symptomatic diverticulosis associated with complications like hameorrhage or infection DiverticuLITIS- inflammation in one or more of the diverticula- get fever and malaise most particular found in sigmoid colon and descending colon

Answer 27

over 50 (decreased mechanical strength) low dietary fibre constipation diet high in salt, meat, sugar obesity NSAID opioid use smoking

Answer 28

LLQ abdo pain - severe change in bowel habit- becoming constipated rectal bleeding nausea and vomiting leukocytosis- (acute diverticulitis) fever- fiverticulitis guarding and tenderness in LLQ- acute diverticulitis

Answer 29

Contrast CT of Abdomen- if suspected acute diveticulitis and raised inflam markers Perforation - erect CXR- pneumoperitoneum (air under diaphragm), riglers sign- (double wall sign air on both sides of bowel wall sign of pneumoperitoneum) Colonoscopy- visualise diverticula FBC- diverticulitis - high WCC and CRP Barium enema- saw tooth appearanceof lumen looks like shell necklace U&E- assess kidney function to know if CT can be performed Diverticular disease 1st line- FBC to see if diverticulitis, U&E to see if renal function okay for CT, CRP to check for diverticulitis. If suspect then contrast CT of abdo- do abdo US if kidneys not good.If suspect oerforation - CXR. colonoscopy if diagnosis of diverticular disease unclear

Answer 30

Asymptomatic Diverticulosis- diet and lifestyle, more fibre and fluids Symptomatic diverticular disease- diet and lifestyle, high fibre Acute diverticulitis without complications- analgesia, oral antibiotics, oral antispasmodic. If doesnt fix in 72 hours then IV AB (ceftriaxone and metronidazole) Acute diverticulitis with complication: bleeding- manage bleed, analgesia, IV AB. 2nd line surgery abscess, perforation, fistulae- radiological drainage(abscess)/laparotomy surgery (perforation) with IV AB and analgesia Recurrent attacks or complictions- surgeyr - Hartmanns procedure

Answer 31

Pneumaturia (air/gas in urine) or faecaluria and recurrent UTIs may suggest a colovesical fistula. Vaginal passage of faeces or flatus may suggest a colovaginal fistula.

Answer 32

Abscesses Perforation Strictures- LBO Fistula formation Prognosis- most dont need surgery. recurrs in 1/3, after surgery 1/4 symptomatic

Answer 33

pain resulting from obstruction from gallbladder or common bile duct, usually bc of a stone so cholelithiasis or choledocholithiasis Pain results when biliary tree contracts to try to move obstruction RF- fair caucasian, fat, fertile, forty, female Oral contraceptive pill, reapid weight loss, sickle cell anaemia. haemolytic conditions= bilirubin breakdown

Answer 34

Cholesterol stones 80%- cholesterol and calcium carbonate Pigment stones- associated with haemolytic conditions such as sickle cell anemia as there is more haemolyisis and therefore more unconjugated bilirubin, composed of calcium bilirubinate

Answer 35

Colicky RUQ pain - usually after ingestion of fatty meal Nausea and vomiting Pain may radiate to right scapula Murphys sign negative - no cholecystitis

Answer 36

US scan- might see thin gallbladder wall MRCP- very sensitive do if US is negative but LFTs are raised or bile duct dilated LFTs- look for ALP ALT and bilirubin.. should be no abnormal LFT as thats liver damage and inflammation.

Answer 37

Asymptomatic stones= no treatment Analgesia, IV fluid, NBM, elective laparascopic cholecystectomy. ERCP can also be used to remove stones or put a stent in blocked duct if stone in CBD. If stones just in gallbladder then elective lap chole is fine

Answer 38

Acute cholecystitis Ascending cholangitis Acute pancreatitis Gallstone ileus (pneumobilia= air in biliary stree on CXR and SBO), gallbladder cancer

Answer 39

5th most common cancer, most in asia men more, over 50 RF- diets high in nitrates/salts like dried foods, smoked foods. Hy.pylori infection, smoking, pernicious anaemia ( Antibodies against gastric parietal cells leading to less IF ad B12 deficiency- macrocytic anaemia from not being able to absorb B12) Mostly adenocarcinoma in lesser cuvature

Answer 40

Abdo pain- vague epigastric, may present as dyspepsia (indigestion- heartburn, bloating, sickness) Weight loss Lymphadenopathy -(Virchows Node)- swelling in left supraclavicular area is a sign of metastatic gastric malignancy Sister Mary Josephs Nodule- metastatic node on the umbilicus Acathosis Nigracans- symmetrical, brown, velvety plaques found on neck, axilla or grin Krukenberg tumour- ovarian mass due to mets of gastric tumour RFs are key diagnostic features

Answer 41

1st- Upper GI Endoscopy with Biopsy: determens if there is cancer. Signet ring cells may be seen (cells look like rings (pale in middle makes outline of ring then nucleus is the signet) CT CAP- to stage after endoscopy. Important for treatment MRI are more accurate at identifying metastatic spread to liver Endoscopic US with FNA- good for staging Urgent Referral for OGD 2 week if dysphagia and over 55 with weight loss + upper abdo pain/reflux/dyspepsia

Answer 42

Surgery- endoscopic mucosal resection, partial gastrectomy, or total gastrectomy Chemotherapy - inc survival if have mets monitor FBC with chemo careful nutrition- monitor B12 if had gastrectomy as may cause neurological symptoms

Answer 43

Complications- malnutrition, paraneoplastic syndrom, mets Prognosis- poor as present late, if diagnosed early 5 year survival is 95%

Answer 44

A chronic condition where stomach contents flow back into the oesophagus 10-30% of people in developed countried due to transiet relaxation of the LOS RF- smoking, alcohol, stress, obesity, pregancny, hiatus hernia, older

Answer 45

Heartburn- burning retrosternal pain- burning sensarion in chest after meal, can be worse after lying down or bending over Acid Regurgitation- acid into mout, sour bitter taste usually after meal Halitosis- bad smelling breath Waterbrash- inc salivation Dysphagia (pain swallowing) and dyspepsia

Answer 46

Resolution of symptoms after 8 week PPI trial is gold standard further test- if doesnt improve with PPI or alarming symptoms Upper GI endoscopy- do if 8 week doesnt work but stop PPi 2 weeks before, also do if alarming symptoms such as over 55, symptoms more than 4 weeks, nor responding to treatment, dyphagia, relapsing symptoms, weight loss) Oesophageal Manometry with pH monitoring - do if endoscopy is negative Barium swallow

Answer 47

Lifestyle- weight loss, stop smoking, smaller and more regular meals, avoid foods that may exacerbate like coffee, acidic fruits, alcohol Medical- Continue PPi if working, add H2 blocker like randitine. Antacids may be useful for symptom relief PPIs can cause hyponatraemia SIADH, increase risk of c.diff infections, hypomagnesaemia, risk of osteoporosis and fracture Surgery- nissen fundoplication. Surgery to increase LOS pressure Monitor- routine endoscopy to assess progression

Answer 48

Complication- oesophageal or ulcer perforation, oesophageal stricture, Barrets oesophagus (metaplasia squamous to columnar epithelium - inc risk of oesophageal adnocarcinoma), adenocarcinoma of oesophagus Prognosis- most respond to PPI treatment and relapse if stop

Answer 49

Perforation of the wall of the GI tract with spillage of bowel contents Causes - Large bowel perforation- diverticulitis, colorectal cancer, appendicitis - Gastroduodenal- perforated gastric ulcer or duodenal ulcer Small Bowel- trauma, infection Tb, crohns Oesophagus- boerhaaves perfroation

Answer 50

Boerhaaves Perforation (complete/transmural rupture of oesophagus after repeated vomiting and chronic alcohol use - get sudden chest pain and subcut emphysema (symptoms similar to pneumonia and respiratory distress), diagnose through CT contrast swallow dont do any sticks or tubes bcs perforation. usually distal 1/3 of oesophagus) Mallory-weiss Tear- longitudinal mucous membrane tear- only mucosa and submucosa, usually at gastric oesophageal junction, causes haematemesis - vomit blood,

Answer 51

Large bowel- peritonitic abdominal pain , rule out AAA Gastroduodenal- sudden severe epigastric pain Oesophageal- severe pain after violent vomiting, neck chest pain and dysphagia all unwell with signs of shock, pyrexia, pallor, dehydration, and have signs of peritonitis (guarding, rigidity, rebound tenderness)

Answer 52

Oesophageal tear: Erect CXR- look for pneumoperitoneum, pleural effusion, pneumothorax CT with oral contrast to confirm or Gastrograffin test CT with IV contrast- for bowel perforation Bloods: FBC- normocytic anaemia U&E- high ureas suggests upper GI bleed not lower because lower is past kidneys so would digest blood, higher then kidneys will filter and get damaged LFT amylase raised in perforation AXR- abnormal gas shadowning, riglers sign (double wall, gas outlining both sides of wall) Gastrograffin Swallow- if suspect oesophageal perforation

Answer 53

For all: IV fluids and IV antibiotics Oesophagus- repair of ruptured oesophagus Gastroduodenal- laparotomy, perforation closed with omental patch, If was a ruptured ulcer due to H.pyrlori then iradicate Large bowel- resection of perforated part- hartmanns procedure. Periotneal lavage- to evaluate bleeding in abdo cavity

Answer 54

Oesophageal- meadistinitis, shock, severe sepsis Bowel- peritonitis Prognosis Gastroduodenal- gastric ulcers have higher morbidity and mortality that duodenal Large bowel-high risk of faecal peritonitis if untreated, death from septicaemia and multi organ failure

Answer 55

vascular rich connective tissue cusions/lumps within the anal canal that may abdnormally enlarge or protrude External- below the dentate line- prone to thrombosis, pain potentially Internal- originate above the dentate line, normally no pain Classified in grades 1-4 1- do nor prolapse out of canal 2- prolapse on defecation but reduce on own 3- manually reduced 4- cant be reduced RF- 45-65 years old from excessive straining from chronic constipation or diarrhoea. an inc in intra-abdominal pressure from pregnancy or ascites, or presence of space occupting lesions inside the pelvis

Answer 56

Rectal bleeding - bright red bleeding on tissue paper, painless Perianal pain/discomfort- accompanied with tenesmus anal pruritus Tender palpable perianal lesion Anal mass Absence of alarm symtpoms Thrombosed haemorrhoids- lots of pain and tender lump will be purplish oedematous, tender subcut perianal mass

Answer 57

Anoscopic Examinaton (pproctoscopy)- 1st line and diagnosis, specific and conclusive for haemorrhoids Clonoscopy/ Flexible sigmoidoscopy- to exlude IBD cancer, do if have symptoms of changes to bowel habit, abdo pain, weght loss, iron deficiency anaemia DRE

Answer 58

1st for all- diet and lifestyle - more fibre and water to soften stools Grade 1- Topical corticosteroids for pruritus Garde 2-3- rubber band ligation Grade 4- surgical haemorrhoidectomy

Answer 59

Complications- anaemia from bleeding, thrombosis, faecal incontinence Prognosis- good after treatment, low recurrence. Surgical haemorrhoidectomy is best long term. less than 20% symptom recurrence

Answer 60

Alcoholic- history of long term alcohol misuse or binge AST is 2 or more times ALT, GGT also raised. Needs alcohol abstinence, nutrition and steroids non-alcoholic steatohepatitis (NASH) - persistant inflammation causes scarring. Insulin resistance, diabetes, obesity, dont drink alcohol. AST less than ALT. Diet exercise and RF control Viral- -Hep a+E : travel to endemic area/ faeco-oral contaminated water - Hep B- blood products unprotected sex, male n male sex, -hep C- blood products, needle sharing, babies AST and ALT in 1000's, have viral serology Drug- paracetomol can cause acute liver failure. AST and ALT in 1000's, serum paracetomol conc. if paracetomol overdose potentially give N-acetyl cysteine and anti emetic Autoimmune- other autoimmune, more women. AST and ALT, ANA ASMA.

Answer 61

Autoimmune Hepatitis- chronic inflam disease of the liver. Usually young females - Type 1 AIH (80%): antinuclear antibodies (ANA) and anti smooth muscle antibodies (ASMA). children and aldults - Type 2 AIH - anti-liver-kidney microsomal-1 antibodies (anti-LKM-1). only children is idiopathic and associated with other autoimmune conditions HLA gene plays a role

Answer 62

Hepatomegaly Jaundice Amenorrhoea Pruritis Spider Angiomata Ascites Splenomegaly Nausea Fatigue Abdominal discumfort

Answer 63

LFT- high ALT adnd AST Serum antibodies - type 1: ANA and ASMA - type 2 : anti-LKM-1 Serum protein electrophoresis- high IgG (hypergammaglobulinaemia Liver Biopsy - to confirm diagnosis. see inflammation and bridging necrosis Pt elongated Increased Bilirubin Decreased serum albumin GGT and ALP should not be markedly raised. If 3x higher than ALT consider bile duct cause If travelled recently test for Hep A: IgM anti HAV- if positive means currently affected If risk of blood products being shared: Tests for Hep B: HBsAg- to look for current infection HBsAb- look for previous infection but could just be vaccine HBcAb- look for previous infection, not vaccine HBeAg- see how infective as indicates how fast replicating HBeAb- whether clearing HBV DNA- see the viral load Test for Hep C: HCV Ab enzyme immunoassay- indicates that there is or was an infection HCV RNA PCR testing- indicates current If been travelling, undercooked seafood, faecal oral like hep A Test for Hep E: IgM anti HEV. Dangerous for pregnent woman as leads to liver failure

Answer 64

Corticosteroids- prednisolone Immunosuppressants- azathoprine Liver transplant

Answer 65

Complications- treatment side effect Prognosis- mod to severe respond in 2 weeks and after 12 months ALT and AST are in normal range

Answer 66

Ischaemic Hepatitis- occurs following acute hepatic hypoperfusion. high AST and ALT levels 1-3 days after insult. Very high LDH- usually means hepaitits

Answer 67

if acute normally resolved by itself Hep B and C may become chronic so would need and antiviral if body cant clear after 6 months

Answer 68

Condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it Inguinal hernia- abdominal or pelvic contents protrudes through the inguinal canal. Most common type - Direct Inguinal Hernia: protrusion through the posterior wall of the inguinal canal- only through the superficial inguinal ring. Develops over time due to straining and is caused by weakness in abdominal. Usually older men. Medial to inferior epigastric vessels Within hesselbachs triangle - inferior epigastric artery, rectus border and inguinal ligament - Indirect Inguinal Hernia: protrusion into the inguinal canal through the deep inguinal ring. caused by defect in abdominal wall that may have been present since birth, an affect infants. Lateral to inferial epigastric vessels When reduced and pressure is applied to deep inguinal ring, indirect hernia will remain reduces but direct will reappear - Femoral hernia- inferolateral to pubic tubercle (inguinal are superiomedial to pubic tubercle -Strangulated hernia: blood supply cut off and hernia contents become ischaemic

Answer 69

Male, age, obesity, reaised intra-abdo pressure(long term cough), chronic constipation, family history, AAA, marfans syndrome, Ehlers Danlos syndrome, prematuriy femoral hernia more common in women

Answer 70

Inguinal Hernias: dull, heavy, dragging pain in association with a bulging hernia visible + palpable groin mass (enlarge with standing or coughing) nausea and vomiting, constipation (strangulated) Femoral Hernia: non reducible cough impulse absent

Answer 71

Clinical diagnosis- observe and palpate Ultrasound scan of groin- if uncertain Ct scan if obese Blood test will show leukocytosis and raised lactate if strangulated hernia

Answer 72

If small and asymptomatic- watchful waiting Treat all if fit for surgery- surgical repair with mesh if large/ symptomatic If unfit for surgery - can leave inguinal hernias and use Truss support belt. Femoral hernias MUST be operated on due to risk of strangulation If obstructed/strangulated- emergency laparotomy - Incarceration: where herniated tissue cant be reduced, pain but no systemic features - Strangulation- blood supply cut of, leads to ischaemia of hernia, usually if femoral. Tender, distended abdomen with absent bowel sounds and systemic features

Answer 73

Post op complications: urinary retention, wound seroma (fluid collections), inguinal wound haemotoma, wound infection, bowel obstruction, dysejaculation (burning) Division of the vas deferens, vascular injury. Mesh infection, groin pain Prognosis- excellent after surgery

Answer 74

Protrusion of abdominal contents into the thorax- usually the stomach -Sliding Hiatal Hernia: 95% GOJ moves above the diaphragm -Rolling Hiatal Hernia- GOJ stays under diaphragm but a separate part of the stomach herniates through the oesophageal hiatus (more urgent as volvulus can result in ischaemia and nerosis)

Answer 75

Obesity, GORD, increased intra abdominal pressure- pregnancy, ascites, chronic cough or constipation

Answer 76

Heartburn, dysphagia(difficult to swallow), odonophagia(pain swallowing, regurgitation, SOB, chronic cough, chest pain GORD symptoms- worse when lying flat Hiccups

Answer 77

Barium swallow- assesses type and size of hernia- sensitive test Upper GI endoscopy- due to symptoms most have this first CXR- retrocardiac bubble

Answer 78

conservative- weight loss and PPI 4-8weeks Surgery (rolling)- laparoscopic/open fundoplication (nissen), hiatoplasy if symptoms persist after conservative

Answer 79

Complications- GORD usually causes sliding complications, upper GI bleeding, gastric ulcers, gastric volvulus If just sliding- symptoms better with medical therapy Hernia repair with anti reflux procedure gives long term cure

Answer 80

Inflammation of the colon due to bacteria, parasites or viruses RF- lack of sanitation, drinking contaminated water, antibiotic use

Answer 81

C.difficile which causes pseudomembranous colitis. Will find a gram positive rod RF- antibiotics and PPI antibiotics like ciprofloxacin, clarithromycin, clindamycin, cephalosporin Can cause perforation or toxic megacolon (use AXR and CT- see yellow plaques on intraluminal wall of colon on sigmoidoscopy)

Answer 82

Diarrhoea- watery or blood stained Blood in mucus and stool Lower abdo pain Malaise and fever

Answer 83

CHESS Campylobacter Haemorrhagic e.coli Entamoeba Histolytica Salmonella Shigella

Answer 84

Stool culture- c.diff toxin to be identified but c.diff antigen positivity only shows exposure to the bacteria rather than current infection. Check for raised WCC too. AXR- show toxic megacolon if c.diff severe Colonoscopy- cisualise inflammation Ask about travel history

Answer 85

Hydration for lost fluids Loperamide- anti diarrhoea Antibitics- depending of infectious agent C.diff= Oral vancomycin for 10 days, if doesnt respond fidaxomicin. If doesnt respond to either then oral vancomycin +/- metronidazole. NO OPIOID as can ic bacterial uptake in gut

Answer 86

Affects the digestive system inlcludes two issues: 1) Crohns 2) Ulcerative Colitis

Answer 87

Disorder of unknown aetiology caused by transmural (non caeseating) granulomatous inflammation of the GI tract Any part of GI tract usually terminal ileum and colon Characterised by skip lesions, cobblestone mucosa (looks like bubbling ulcers whereas UC looks like flat ulcers), string sign on barium swallow Th1 mediated RF- white, FH of Crohns, 15-40 years and 60-80, SMOKING

Answer 88

RLQ Abdo pain- defecation makes better Prolonged diarrhoea (no blood) Perianal lesions- skin tags, fistulae, abscesses, scaring Lethary Malabsorption- weight loss and anemia (affects all layers) Fatigue, fever, lethargy Symptoms away from intestinal symptoms: motuh ulcers, arthropathy (joint pain), skin lesions (erythema nodosum- shins) and pyoderma gangrenosum (leg ulcers). Anterior uveitis (painful red eye with loss of vision and photophobia), episcleritis (painless red eye).

Answer 89

Colonoscopy + biopsy- deep ulcers, skip lesions and cobblestone appearance Histology- transmural inflammation with non-caseating granulomas Barium enema- kantor's string sign and rose thorn ulcers Faecal calprotectin- raised in IBD not IBS FBC_ anaemia from inflammation and chronic blood loss, iron malabsorption, B12/folate malabsorption Increased CRP and ESR- inflam markers Stool microscopy and culture - exclude infection Serum vitamin B12 (absorbed in terminal ileum which crohns affects) and folate- reduced Plain AXR or Ct abdomen

Answer 90

induce remission with corticosteroids: prednisolone or budenoside Maintain Remission with Immunomodulators- Azathiprine 1st line, IF NOT methotrexate. Stop smoking Biologics- Infliximab No surgery as skip lesions

Answer 91

Complications- small bowel obstruction (strictures and fistulae formations), anemia (lack B12), malignancy, kidney stones, gallstones, perianal fistula (fistulotomy or draining seton with MRI to visualise and) and abscess (incision and drainage) Prognosis- chronic disease, relapse and lots of complications

Answer 92

A type of IBD that involves the rectum and extends proximally to affect a variable length of the colon. If affects just rectum- proctitis Affects part of colon (left sided colitis Entire colon- pancolitis Never goes past ileocaecal valver unless its backwash ileus Only involves colonic mucosa 20-40 years or older than 60 RF- genetic predisposition (HLA-B27), white, FH of IBD. Smoking is protective effect

Answer 93

Bloody diarrhoea- episodic or chronic LLQ pain weight loss rectal bleeding- mild disease may have intermittent rectal bleeding associated with mucus. Abdominal pain and cramps Extraintestinal symptoms: Joint- peripheral arthritis and akylosing spondylitis Skin- erythema nodosum and pyoderma gangrenosum Occular- episcleritis more common than uveitis (painless red eyes more common than painful)

Answer 94

Colonoscopy and biopsy- continuous distal disease, no granulomas, crypt abscesses, depletion fo goblet cells If severe colitis- flexible sigmoidoscopy may be done as colonoscopy may cause perforation Faecal calprotectin- high (makes sure not IBS) Stool Microscopy and culture- rule infection LFT- primary sclerosing cholangitis Bloods- high ESR and CRP, anaemia, leukocytosis AXR- thumbprinting, loss of haustra, toxic megacolon, psudopoyps Toxic megacolon- massive transverse colon, loss of haustra, NBM IV fluids, NGT, no colonsscopy) Barium enema- lead pipe appearance

Answer 95

Mild <4 bowel movements per day, small amounts o blood, no temp, no change in pulse rate, no anemia, ESR 30 or lower Moderate 4-6 bowel movments per day, some blood, o temp, no change in pulse rate, no anemia, ESR 30 or lower Severe 6+ per day plus : visible blood in stool, pyrexia, pulse rate higher than 90bpm, anemia, ESR over 30

Answer 96

MILD TO MODERATE UC 5-ASA (mesalazine) topical if distal or oral if more severe (topical if proctisis or proctosigmoiditis, topical+ oral if left sided or extensive). If topical mesalazine doesnt induce remission then add oral mesalazine then oral corticosteroid Maintain with oral/topical mesalazine or with azathioprine if severe relapse or 2 or more exacerbations in one year ASA can cause agranulocytosis so monitor FBC SEVER UC IV corticosteroids (hydrocortisone) or IV ciclosporin if not improving or worsening. IV fluids NBM Infliximab If doesnt improve then urgent colectomy Total colectomy= cure

Answer 97

Complications: Colonic Adenocarcinoma Toxic megacolon Primary sclerosing cholangitis :inflammation and fibrosis of intra and extra-hepatic bile ducts. UC + Cholestasis (ie. jaundice and pruritus. Raised ALP and GGT). ERCP/MRCP can be used to diagnose, showing ‘beaded’ appearnace of biliary structures. Associated with p-ANCA and ASMA. Can lead to cholangiocarcinoma (PSC is main risk factor for cholangiocarcinoma, raised CA19-9 levels). Prognosis- same as people without UC

Answer 98

Chronic condition characterised by abdominal pain and associated bowel dysfunction 20-39 Female (over 50 is unusual) RF: under 50, female, previous enteric infection, history of physical or sexual abuse, FHx, stress

Answer 99

Abdominal Discomfort- cramping in lower abdomen, relieved by defecation Change in bowel habits associated with pain- defecation relieves Abdominal Bloating/Distension- improved with defecation or farting Mucus in stool Eating makes worse Alternates between diarrhoea and constipation ABC (abdo pain, bloating, change in habit) for at least 6 months no blood( blood in UC and cancer), not more frequent at nigh (crohns), no weight loss (colorectal carcinoma, crohns, UC), no anamia (crohns, severe UC)

Answer 100

Rome IV(4) Recurrent abdominal pain on average 1 day week at least during last 3 months associated with 2 or more of: pain on defecation change in stool frequency change in stool form or appearance

Answer 101

FBC- normal, if abnormal then not IBS Faecal Calprotectin- should be normal, if raised then some sort of bowel inflammation Faecal occult blood test Coeliac screen IgA-TTG CRP, ESR

Answer 102

Lifestyle- fibre, manage stress, educate and reassure If mostly constipated- laxatives. use bulk-forming laxative like ispaghula, avoid laculose (makes gas worse) If diarrhoea- antidiarrhoeals like loperamide Antispasmodics for pain

Answer 103

Complications- diverticulosis, depression, sleep disorders, damage to fam and work relationships Prognosis- no long term complcations. symptoms tend to recur particularly with stress, emotional difficulty or dietary indiscretions

Answer 104

Severe liver dysfunction leading to jaundice, encephalopathy and coagulopathy Hyperacute = less than 7 days Acute= 1-4 weeks Subacute= 4-12 weeks Chronic= progressive deterioration of hepatic function over at least 26-28 weeks (6 months) - Stigmata of Chronic LIver disease= spider naevi, gynaecomastia, dupuytrens contracture, palmar erythema - Sign of decompensation= ascites, jaundice, encephalopathy

Answer 105

Viral Hepatitis (a/b) Paracetomol overdose Idiopathic Alcohol excess Acute fatty liver of pregnancy

Answer 106

Jaundice- less conjugated bilirubin, causes pruritus Encephalopathy- ammonia not being removed, so lose consciousness- can lead to cerebral oedema- toxins in brain lead to problems with function so cause asterixis Coagulopathy- liver (vit K) clotting factors (2,7,9,10). Life threatening bleeds Nausea and vomiting Fever lethargy malaise Acute fatty liver pregnancy- jaundice following abdo pain and pruritis during pregnancy

Answer 107

PT- raised= coagulopathy, best indicator of liver function LFTs- high bilirubin, AST, ALT, ALP, GGT. Low albumin (leukonychia) Hypoglycaemia Viral serology, paracetomol levels- look for cause EEG- monitor encephalopathy

Answer 108

N-acetylcysteine (for paracetomol overdose) Encephalopathy- give lactulose. IV mannitol can help to reduce cerebral oedema Coagulopathy- vitamin K and FFP Liver transplant- considered for most

Answer 109

Complications- infection, coagulopathy, cerebral oedema (raised ICP), respiratory failure Prognosis- depends

Answer 110

Malfunction of the intestinal wall resulting in insufficient absorption of breakdown products (happend in IBD, Coeliac, lactose intolerance) Global malabsorption- in diseases causing diffuce mucosal damage or reduction in absorptive surface like coeliac disease Partial malabsorption - localised absorption impairment resulting in deficiencies in specific nutrients (vit B12 in IBD or terminal ileum affected issues) Maldigestion- insufficient secretion of pancretic enzymes or bile preventing adequate breakdown of food in intestinal lumen (exocrine pancreas insufficiency or cholestasis)

Answer 111

Diarrhoea Steatorrhea- floating and foul smelling Abdominal Distension Weight loss and fatigue Partial malabsorption- sympoms specific to nutrient deficiencies

Answer 112

Blood tests- anaemia, vitamin deficiencies D-xylose absorption test- test absorptive function of upper small intestine

Answer 113

Oral supplementation of fluid, nutrients and vitamins Calorie and protein enriched diet Severe cases- IV nutrition

Answer 114

Important concequence of and contributor to chronic disease 1 of the following: - BMI <18.5 - Unitntentional weight loss more than 10% within last 3-6 months - BMI less than 20 and unintentional weight loss more than 5% within last 3-6 months 10% of people over 65 are malnourished with most living independently RF_ crohns, dysphagia, socially isolated, low income

Answer 115

Unintentional weight loss lack interest in eating and drinking Feel tired all the time Feel weak all the time Getting ill often and taking long to recover

Answer 116

MUST- malnutrition universal screen tool - should be done if admitted to nursing homes or hospital or if concerned - Used BMI, recent weight change and present of acute disease - characterises into risk

Answer 117

Dietician support Food first approach with clear instructions (do this before supplements) Oral Nutritional Supplements- taken between meals - not a replacement If severe- feeding tube (enteral (food through GI tract) or paraenteral (iv into a central vein) - enteral feeding can cause diarrhoea - total paraenteral used in nutritionally compromised surgical patients

Answer 118

Refeeding syndrome- metabolic abnormalities which occur after feeding someone after starvation Hypophosphataemia, hypokalameia, hypomagnesiumaemia (low magnesium= torsades de pontes) Prevention- if a patient hasnt eaten for more than 5 days, aim to refeed at 50% or less of requirements for first 2 days

Answer 119

Inflammation of lymph nodes in the intra abdominal mesentery recent viral intestinal infection like gastroenteritis (MOST COMMON CAUSE) children and teenagers mostly mimics appendicitis sometimes

Answer 120

Abdo pain- RLQ but can be widespread General abdo tenderness fever mesenteric lympth node enlargement Diarrhoea and vomiting sometimes history of recent viral intestinal infection

Answer 121

Abdominal ultrasound Bloods

Answer 122

Often self limiting- doesnt need treatment Paracetomol or ibuprofen for pain Drink lots of fluids Antibiotics if caused by bacterial infection

Answer 123

more common in men 60-70 yrs Squamous cell carcinoma (upper2/3): RFs alcohol, smoking, diet low in fruit+veg, HPV, Hot beverages Adenocarcinoma (lower 1/3): Rfs obesity, male, GORD, Barretts oesophagus, hiatus hernia

Answer 124

Progressive dysphagia- first difficult to swallow solids then liquids too Odynophagia- pain when swallowing Rapid Weight loss- stop eating and cancer multiplying Signs of Advanced disease: hoarseness (recurrent laryngeal nerve pressed means SCC as upper 2/3 affected), Horners syndrome (ptosis, miosis and anhidrosis) Signs of upper GI bleeding: Haemetemesis, melaena, raised urea (may have anaemic symptoms like fatigue or SOB)

Answer 125

Upper GI Endoscopy with biopsy- gold standard for pt with dysphagia odynophagia and weight loss CT CAP/MRI for staging to treat

Answer 126

Surgery- oesophagectomy with adjunct chemotherapy Chemoradiotherapy is better than radiotherapy alone EITHER: preoperative chemoradiotherapy then surgery OR surgery and then perioperative chemotherapy

Answer 127

Complications- postop pneumonia, aspiration pneumonia, post-resection reflux Prognosis- poor due to aggressive course and late presentations

Answer 128

Achalasia is incomplete relaxation of the LOS (inc pressure of LOS) Dysphagia is not progressive in achalasia unlike oesophageal cancer, will have dysphagia of solid and liquid from the start in achalasia Investigation: Manometry- finds increased resting pressure on LOS Barium swallow; birds beak appearance (narrowed at LOS) CXR- wide mediastinum, fluid level Management of achalasia: penumatic dilation or hellers cardiomyotomy to relieve pressure on LOS)

Answer 129

Primary Pancreatic ductal adenocarcinoma presents at 60-80 yrs RF_ smoking, FHx, chronic pancreatitis, high alcohol consumption, T2DM, obesity, inherited genetic syndromes

Answer 130

Painless jaundice (if painful then usually obstruction) Palpable mass in RUQ Pale stools (reduces stercobilinogen) Dark urine (reduced urobilinogen + increased conjugated bilirubin in urine) If cancer at head of pancreas then bile flow obstructed- jaundice Pruritus- may have scratch marks, because of bile salts in circulation Non specific upper abdo pain or discomfort (if back pain the retroperitoneal metastases) Weight loss and anorexia Courvoisers Law = palpable gallbladder in a pt with painless obstructive jaundice is usually malignancy

Answer 131

High red Abdo Ct scan- find mass in pancreas. will have a double duct sign showing dilation of both pancreatic and common bile duct Abdo US if CT unavailable- detect mass, dilated bile duct and liver mets LFTs- degree of obstructive jaundice. Bilirubin, ALP, GGT, elevated in obstructive jaundice. ALT may be slightly elevated but thats liver CA 19-9 biomarker

Answer 132

Whipple's resection (pancreaticduodenectomy)- performed for resectable lesions at head of pancreas. May cause dumping syndrome (food from stomach to bowel to fast, can cause tachy and diarrhoea), may also cause peptic ulcer disease - Give adjuvant chemotherapy after surgery ERCP with stenting for palliative

Answer 133

Complication- surgical comp;ications (pancreatic leaks and fistula), cholangitis, DVT and PE, duodenal obstruction Prognosis- aggressive treatment and poor prognosis as present late

Answer 134

PUD= ulceration of the GI tract, due to exposure to gastric acid and pepsin. Peptic ulcers : duodenal ulcer more common than gastric ulcer Gastritis- histological presence of mucosal inflammation Duodenal ulcer- 30 yrs old Gastric ulcer 50yrs old Common causes; Helicobacter pylori and NSAID use other RFs: smoking, older, had PUD before, FHx PUD, patient in intensive care

Answer 135

Epigastric pain- gnawing - Gastric ulcer- pain right after meals (weight loss) -Duodenal ulcer- pain a few hours after eating (pain may be relieved by eating so weight gain) -Perforated ulcer- acutely unwell and haemodynamically unstable (arrythmia, consciousness level, peripheral cyanosis) Epigastric tenderness

Answer 136

Nausea, vomiting and loss of appetite so may lose weight

Answer 137

Upper Gi endoscopy- will show ulcerations and can biopsy for H.pylori. Do this immediately aka same day if have acute GI bleeding and dyspepsia Helicobactor pyrlori carbon-13 urea breath test or stool antigen test- use if after endoscopy still unsure whether infected with H.pylori. cant have PPI for 2 weeks and ABx for 4 weeks for this test to work Erect CXR- -pneumoperitoneum = perforated duodenal ulcer. - Dome sign= perforated gastric ulcer Raised urea= upper GI bleed Faecal Occult Blood test FBC- only if has Gi bleeding or seems anaemic

Answer 138

Lifestyle: less smoking and alcohol intake H,pyrlori positive: TRIPLE THERAPY (PPI aka omeprazole + ABx amoxiccillin + broad ABx Clarithromycin) - if allergic to penicillin then metrandazole. 1 week course, twice daily H.pylori negative: atrop drug causing e.g. NSAID, offer ulcer healing therapy which is 4-8 weeks of PPi therapy (omeprazole 20mg) - For gastric ulcers repeat endoscopy 6-8 weeks later to ensure healing and rule our malignancy -For duodenal ulcers repeat urea breath test for h.pylori 6-8 weeks later.

Answer 139

Complication- Upper GI Bleeding - Haemorrhage causes haematemesis, meleana and anaemia - Perforation- shock and peritonitis Prognosis- with PPI duodenal heal in 4 weeks and gastric 8 weeks

Answer 140

A pus collection in the perianal region Anal abscesses are the acute manifestation of a purulent infection in the perirectal area 30-60% of anal abscesses progress into anal fistulaes

Answer 141

An abnormally chronically infected tract communicating between the rectum and the perineum Anal fistulaes are the chronic manifestation of purulent infections

Answer 142

Men 20-60 years old Cause: flow obstruction and bacterial infection of the anal crypt glands. Less common cause: IBD (Crohns> UC), diverticulitis, appendicitis and malignancy

Answer 143

Perianal abscess- dull perianal discomfort and pruritus. Erythematous, subcutaneous mass near the anus. Purulent discharge, Fever and malaise as its an infection Perianal fistula- pus drainage (discharge) from anal canal or surrounding perianal skin. Causes pain on defecation. Constant throbbing pain that worsens when sit down. Smelly discharge ON DRE- fluctuant (pressure to one end of lsion transmits pressure to every other point thats swolln), indurated mass (thick and hard). Pain with pressure

Answer 144

Clinical examination first/DRE then: CT/MRI or Anal ultrasonography: tests to confirm deeper abscesses MRI pelvis: best investigation to characterise fistulae course Further testing with endoscopy, MRI, fistula probe to identify other possible fistulae and comorbidities like cancer or IBD

Answer 145

SURGERY- surgical incision and drainage of abscess under local anaesthetic (to prevent spread of infection =sepsis risk). After surgery sitz baths, analgesics+ stool softeners, antibiotics (ONLY ABs IF IMMUNOCOMP) Fistulotomy- cutting alond the length of the fistula to open it in order for it to be drained IF complex perianal fistulae (e.g. in crohns)= seton placement- a piece of surgical thread run through fistula to allow continuous drainage while the fistula heals- it makes sure fistula doesnt heal with pus still inside.

Answer 146

Complications- recurrence, damage to internal anal sphincter, incontinence, persisting pain Prognosis- high recurrence rate if not completely excised

Answer 147

Inflammation of the peritoneal lining of the abdominal cavity, can be localised to a part of peritoneum or generalised Localised= appendicits, cholecystitis and diverticulitis Spontaneous bacterial peritonitis- usually seen in patients with ascites, secondary to liver cirrhosis. Due to infection of the ascitic fluid. Escherichia coli most common

Answer 148

Abdo pain/ tenderness Ascites Fever nausea and vomiting, diarrhoea, altered mental status

Answer 149

Paracentesis (ascitic fluid absolute neutrophil count)- >250 cells/mm^2 is diagnstic for sprontaneous bacterial peritonitis Ascitic fluid culture- determine the causitive organism

Answer 150

Empirical IV Antibiotics with cefotaxime IV Albumin If ascitic fluid protein conc <15g/Lor had a previous episode of SBp then continuous antibiotic prophylaxis (oral ciprofloxacin or norfloxacin)

Answer 151

Complications- sepsis, renal failure Prognosis- 69% recurrence in one year. Renal dysfunction predicts mortality

Answer 152

Vit B12= Cobalamin Role in RBC formation and myelination of the nervous system In animal products Absorbed in terminal ileum and requires IF

Answer 153

Pernicious Anaemia- autoantibodies against IF made by gastric parietal cells. Inc risk of gastric cancer, may have other autoimmune discorders Post gastrectomy (gets rid of gastric parietal cells) Vegan diet Terminal ileum affected conditions- crohns disease or ileocaecal resection

Answer 154

Anaemia signs- fatigue, pallor, SOB Peripheral neuropathy- tingling, numbness, paraesthesia Demantia Glossitis (may present as sore tongue)

Answer 155

Folate= Vitamin B9 Essential coenzyme that enables critical biochemical reactions for DNA synthesis and amino acid metabolism From green leafy veg, fruits, liver, bread, cereal

Answer 156

Malabsorption aka in small bowel disease from IBD or coeliac disease Malnutrition from chronic alcohol use Increased requirement from pregnancy Drug related- methotrexate or antiepileptics

Answer 157

Signs of anaemia- fatigue, pallor, SOB Glossitis Fetal spina bifida (neural tube defects) if maternal deficiency NO NEUROLOGICAL SYMPTOMS

Answer 158

Signs of macrocytic, megaloblastic anaemia: low Hb, high MCV, hyperchromic RBC, hypersegmented neutrophils Vit B12 pernicious anaemia- test for anti-IF or antiparietal cell (anti-IF is more specific) Homocysteine- elevated in both deficiencies Methylmalonic acid (MMA)- elevated in B12 normal in folate

Answer 159

Vit B12 def- IM supplementation of Vit B12 (hydroxocobalamin) Folate- oral folate supplementation, nutritional councelling to inc folate in diet - folate given to preg women as risk of neural tube defect such as spinal bfida and anencephaly (400mcg folic acid until 12th week of preg) REPLACE B12 BEFORE FOLATE PROTECTS AGAINST SUBACUTE COMBINED DEGENERATION OF THE CORD