GI & General Surgery Flashcards
1
Q
What is the treatment for H.pylori?
A
Triple therapy
PPI + amoxicillin + ciprofloxacin/metronidazole
If penicillin allergic
PPI + ciprofloxacin + metronidazole
2
Q
How is H.pylori infection diagnosed?
A
Urea breath test
C13 stool test
3
Q
What is the most common type of peptic ulcer?
A
Duodenal ulcer
4
Q
How do peptic ulcers present?
A
Abdominal pain
Nausea/vomiting
Dyspepsia
May be history of NSAID use
Gastric ulcer - worse after eating
Duodenal ulcer - worse when hungry.
Can present with bleeding - Melaena, coffee ground vomiting
5
Q
How are H.pylori positive peptic ulcers managed?
A
History of NSAID use - 8 weeks of PPI, then eradication therapy
No history of NSAID use - straight in with eradication therapy
Eradication therapy = PPI + Amoxicillin + Clarithromycin/Metronidazole
2nd line = PPI + Amoxicillin + Doxycycline
If penicillin allergy = PPI + Clarithromycin + Metronidazole
6
Q
How is H.pylori negative peptic ulcer managed?
A
No NSAID use - 4 weeks PPI
NSAID use - 8 weeks PPI
7
Q
How is a peptic ulcer managed if they present with acute bleeding?
A
IV PPI
8
Q
If a peptic ulcer perforates, what is seen on x-ray?
A
Free air under the diaphragm (Pneumoperitoneum)
9
Q
What is the most common cause of non-progressive dysphagia?
A
Achalsia
10
Q
What is achalasia?
A
Failure of the lower oesophageal sphincter to relax when swallowing
11
Q
How is achalasia diagnosed?
A
Birds beak appearance on barium swallow
Increased lower oesophageal sphincter tone on oesophageal manometry
12
Q
How is achalasia managed?
A
Balloon dilation
13
Q
How does achalasia present?
A
Dysphagia of both solids and liquids
Dyspepsia
Regurgitation
14
Q
What does birds beak appearance on barium swallow indicate?
A
Achalasia
15
Q
How is GORD managed ?
A
Trial a PPI for 4 weeks
If no improvement- test and treat for H pylori
16
Q
What is Barrett’s oesophagus?
A
Normal squamous cell epithelium of the oesophagus turns to columnar epithelium
17
Q
How do you monitor Barrett’s oesophagus?
A
Endoscopy every 3-5 years
If dysplasia is seen - resection/ablation
18
Q
What are the indications for Upper GI 2WW?
A
Dysphagia in any person
Upper abdominal mass
> 55 years, weight loss + dyspepsia/abdominal pain/reflux
19
Q
What do you do if GORD has not improved after 4 weeks of PPI?
A
Trial h2 receptor antagonist
if >55 refer to secondary care
Otherwise test and treat for H.pylori
20
Q
How long does PPI treatment need to be stopped before testing for H.pylori?
A
2 weeks
21
Q
What is the most common type of oesophageal cancer seen in those with a history of GORD/Barrett’s oesophagus?
A
Adenocarcinoma
22
Q
How does oesophageal cancer present?
A
Progressive dysphagia
Weight loss
23
Q
What is the most common cause of an upper GI bleed?
A
Peptic ulcer
24
Q
How does bleeding due to a peptic ulcer present?
A
Melaena
Coffee ground vomiting (dark red blood)
25
What is the most common cause of bright red haematemesis?
Mallory-Weiss tear
26
What is the Initial management of suspected variceal bleeding?
Terlipressin + prophylactic broad-spectrum abx
| Then endoscopy.
27
How is variceal bleeding treated?
Band ligation unless bleeding profusely
| If bleeding profusely and unable to visualise with endoscopy - sengstaken-Blakemore tube
28
What medication is given for prophylaxis of variceal haemorrhage?
Propranolol
29
How can you differentiate between a lower or upper GI cause of bleeding?
Check urea
Upper GI = high urea
Lower GI = low/normal urea
30
How does Crohn’s disease present?
Abdominal pain
Diarrhoea (non-bloody)
Weight loss, lethargy
Mouth ulcers
31
What marker is raised in inflammatory bowel disease?
Faecal calprotectin
32
What is seen on histology for Crohn’s disease?
```
Goblet cells
Transmural inflammation
Skip lesions (Cobblestone appearance)
Granulomas
Rose thorn ulcers
```
33
How is remission induced in Crohn’s disease?
1. Oral prednisolone / IV hydrocortisone
2. ADD Azathioprine (check TPMT activity first) - if TPMT activity deficient then add Methotrexate
3. Add biologic
34
How is remission maintained in Crohn’s disease? (first line and second line)
1st line = azathioprine or mercaptopurine
| 2nd line = methotrexate/infliximab/Adalimumab
35
Which liver condition is associated with ulcerative colitis?
```
Primary sclerosing cholangitis
Jaundice
Itchiness
Raised ALP and bilirubin
MRCP = diagnosis
```
36
How does ulcerative colitis present?
Bloody diarrhoea
Abdominal pain - more so on the left side
Urgency
Tenesmus - feeling the need to open the bowels when the bowels are empty.
37
What is seen on histology for ulcerative colitis?
Ulcerative colitis:
Goblet cell depletion
Submucosal inflammation only
Continuous inflammation
Crypt abscesses
Pseudopolyps
Loss of haustrations
38
How do you induce remission in ulcerative colitis?
Topical sulfasalazine/mesalazine (aminosalicylate)
If no improvement - try oral
If no improvement - oral prednisolone
39
How do you induce remission in severe UC?
IV methylprednisolone / IV Hydrocortisone
40
How to maintain remission in UC?
1. Topical sulfasalazine/mesalazine
2. Oral sulfasalazine
3. Oral Azathioprine/Mercaptopurine (If severe UC/ 2 exacerbations in last year - go straight to this)
41
How to maintain remission in someone with severe UC or who has had 2 exacerbations in a year ?
Oral azathioprine/mercaptopurine
42
What classes as mild UC?
Less than 4 stools a day, not much blood
43
What classes as moderate UC?
4-6 stools a day, varying amount of blood, no systemic upset
44
What counts as severe UC?
More than 6 bloody stools a day
| Needs to be some form of systemic upset - fever, anaemia, tachycardia, raised WCC
45
Which type of IBD is smoking protective for?
Ulcerative colitis
46
What does an ileostomy look like?
Spouted
Liquid stool
Usually RIF
47
What is a colostomy?
Flat
Solid stools
Usually LIF
48
What is the diagnostic criteria for IBS?
Abdominal pain which improves on defaecating
Bloating
Change in bowel habit - diarrhoea/constipation
May be mucus in stool
49
Is faecal calprotectin raised in IBS?
No - normal
50
How is IBS managed?
For diarrhoea - Loperamide
For cramping - Buscopan
For constipation - Laxatives
AVOID Lactulose - lactulose can cause bloating
2nd line = Amitriptyline
3rd line = SSRI
51
What is the second line treatment for IBS?
Amitriptyline
52
What is coeliac disease?
Autoimmune sensitivity to gluten
53
How does coeliac disease present?
```
In children - failure to thrive
Diarrhoea
Abdominal pain
Bloating
Steatorrhoea (greasy stools hard to flush)
```
Symptoms of malabsorption - anaemia, fatigue
54
Which autoantibody is raised in coeliac disease?
Anti-TTG antibody
55
How long does gluten need to be introduced before checking anti-TTG levels?
6 weeks
56
What is seen on histology for coeliac disease?
Villous atrophy
| Crypt hyperplasia
57
Which vaccine do those with coeliac disease need?
Pneumococcal vaccine every 5 years
58
Which electrolyte abnormalities are seen in refeeding syndrome?
Low phosphate
Low magnesium
Low potassium
59
What are the two most common causes of small bowel obstruction?
Adhesions and hernias
60
What is the most common cause of large bowel obstruction?
Malignancy
61
How does bowel obstruction present?
Abdominal pain
Constipation
Green billous vomiting
Tinkling bowel sounds
62
How is bowel obstruction treated?
Nil by mouth
Large bore NG tube with free drainage
IV fluids
Treat underlying cause
63
What is an ileus?
Pseudoobstruction due to halting of peristalsis
Presents the same way as mechanical bowel obstruction
Absent bowel sounds
64
What is a sigmoid volvulus and how is it seen on X-ray?
Sigmoid colon wraps around itself and its own mesentery, causing a closed-loop obstruction
Coffee bean sign
65
What is the main risk factor for a sigmoid volvulus?
Chronic constipation
66
What are the three complications of a hernia?
Incarceration
Obstruction
Strangulation
67
How is an inguinal hernia managed?
Surgical mesh repair even if asymptomatic (not urgent)
68
How is a femoral hernia managed?
Urgent surgical repair due to high risk of strangulation and obstruction
69
What are risk factors for diverticular disease?
Old age
Low fibre diet
Obesity
NSAID use
70
How does acute diverticulitis present?
Abdominal pain in left iliac fossa
Diarrhoea
Fever
May be nausea/vomiting
Rectal bleeding
71
What are complications of acute diverticulitis?
```
Peritonitis
Haemorrhage
Perforation
Peridiverticular abscess
Large haemorrhage
Fistula
```
72
What is the management of acute diverticulitis?
If uncomplicated - oral Co-amoxiclav
Avoid solid foods until symptoms have resolved
Review after 48-72 hours
If no improvement - admit for IV Ceftriaxone + metronidazole
If complicated - hospital admission
73
What is mesenteric ischaemia?
Lack of blood flow through the mesenteric vessels causing intestinal ischaemia - due to embolus
74
What is the biggest risk factor for mesenteric ischaemia?
Atrial fibrillation
75
How does mesenteric ischaemia present?
Sudden onset Acute abdomen
Pain worse on eating
Lab results show increased lactate
76
How is mesenteric ischaemia diagnosed?
First line = Blood gas for raised lactate
Definitive diagnosis =
CT angiogram Abdomen
77
How is mesenteric ischaemia managed?
Immediate laparotomy
78
What is the management of spontaneous bacterial peritonitis?
IV cefotaxime
79
What medication is given prophylactically in patients who have had an episode of spontaneous bacterial peritonitis?
Oral ciprofloxacin (ciprofloxacin is a quinolone Abx)
80
What is the 2WW criteria for lower GI malignancy?
40 and over + abdominal pain + weight loss
50 and over + unexplained rectal bleeding
60 and over + change in bowel habit
60 and over + unexplained iron deficiency
81
How does colorectal cancer present?
```
Change in bowel habit - usually loose
Blood in stool
Abdominal pain
Iron deficiency anaemia
Weight loss
```
82
How is colorectal cancer investigated?
If the patient does not meet 2WW criteria - FIT (Faecal immunochemical tests) human haemoglobin stool testing
Definitive diagnosis = Colonoscopy
83
What kind of bacteria is clostridium difficile?
Gram-positive rod shaped
Anaerobic
84
Which drugs cause clostridium difficile infection?
Clindamycin
Cephalosporins - Cefuroxime, Cefotaxime, Ceftriaxone
Quinolones e.g. ciprofloxacin
Amoxicillin
PPIs !!
85
How does clostridium difficile infection present?
Diarrhoea
Abdominal pain
Raised white blood cell count
History of broad spectrum antibiotics
86
How is clostridium difficile infection diagnosed?
Presence of toxin in stool
87
What if the stool is positive for clostridium difficile antigen but negative for the toxin?
Monitor patient but no antibiotics needed
88
How is clostridium difficile managed?
First line = oral vancomycin
89
What is second line for clostridium difficile?
Oral fidaxomicin
90
What do you test for in coeliac disease?
Total IgA and IgA TTG antibodies
If total IgA is low - do IgG TTG antibodies
91
What is an incarcerated hernia?
A hernia which cannot be reduced back into its normal position
Risk of strangulation or obstruction
92
What is a strangulated hernia?
Hernia is non reducible and the base of the hernia is so tight that it cuts off blood supply
Leads to ischaemia
Presents with significant pain
A strangulated hernia = surgical emergency
93
What is a direct inguinal hernia?
Hernia passes through Hesselbach’s triangle
94
What is an indirect inguinal hernia?
Bowel herniates through the inguinal canal
95
How can you differentiate between a direct and indirect inguinal hernia?
Reduce hernia, apply pressure to deep inguinal ring and ask patient to cough,
Indirect = hernia remains reduced
Direct = hernia comes back up
96
How is life threatening c diff managed?
Oral Vancomycin + IV Metronidazole
97
Which skin condition is associated with coeliac disease? How is it treated?
Dermatitis herpetiformis - itchy blistering rash on extensor surfaces and buttocks
Treated with Dapsone
98
Which type of cancer is associated with coeliac disease?
Enteropathy-associated T cell lymphoma
99
How long must patients eat gluten before testing for anti-TTG?
6 weeks
100
Which part of the bowel is most commonly affected in Crohn’s disease?
The terminal ileum
101
Which part of the bowel is most commonly affected in ulcerative colitis?
Rectum
102
How do you treat a recurrent episode of C diff within 12 weeks of symptom resolution?
Oral fidaxomicin
| If it has been more than 12 weeks, can use vancomycin or fidaxomicin
103
What is the major adverse effect of aminosalicylates e.g. sulfasalazine/mesalazine?
Agranulocytosis
If someone presents with infection in ulcerative colitis taking aminosalicylates - check FBC
104
What should you do if someone taking an Aminosalicylate (e.g. Sulfasalazine) presents with an infection? Why?
Check FBC
Risk of Agranulocytosis
105
Which laxative should be avoided in IBS and why?
Lactulose
Risk of bloating
106
Which blood marker is raised in mesenteric ischaemia?
Lactate
107
Where should you do a biopsy to diagnose coeliac disease?
Duodenum
108
Which test is recommended to check if H.pylori has been eradicated?
C13 urea breath test
109
How does vitamin A deficiency present?
Night blindness
110
How does vitamin B1 (thiamine) deficiency present? What are causes of this deficiency?
Causes = Alcohol excess, malnutrition
Can lead to Wernicke's/Korsakoff's
111
How does vitamin B3 (niacin) deficiency present?
Also known as Pellagra
Dermatitis
Diarrhoea
Dementia
112
How does vitamin B6 deficiency present?
Peripheral neuropathy
Sideroblastic anaemia
Can be caused by isoniazid
113
How does vitamin C deficiency present?
Bleeding
Poor wound healing
Gingivitis
Bruising
114
Crypt hyperplasia vs. crypt abscesses
Crypt abscess - UC
Crypt hyperplasia - coeliac disease
115
Patient with UC has a rash on extensor surfaces and buttocks - how is this treated?
Dapsone
116
What do you give to someone waiting for endoscopy for suspected variceal bleeding?
Terlipressin + broad-spectrum abx
117
Which cancer is associated with Achalasia?
Squamous cell carcinoma of the oesophagus
118
Where is the best place to take a biopsy from in Crohn's disease?
Ileum
119
Where is the best place to take a biopsy from in Ulcerative Colitis?
Jejunum
120
What is the difference between mesenteric ischaemia and ischaemic colitis?
Ischaemic colitis – large bowel
Mesenteric ischaemia – small bowel
Mesenteric ischaemia - urgent laparotomy
Ischaemic colitis - conservative management
121
What is seen on CXR in ischaemic colitis?
Thumbprinting
122
What is Toxic megacolon?
A complication commonly associated with UC
Swelling and inflammation which spreads into the deeper layers of colon
Colon stops working and widens
123
How does Toxic megacolon present?
```
Abdominal pain
Fever
Shock
Tachycardia
Diarrhoea
```
124
How is toxic megacolon diagnosed?
Abdominal XR showing huge dilated loops of bowel
125
How is toxic megacolon managed?
IV fluids + IV steroids
| If no improvement in 48-72 hours – consider for surgery
126
What do you need to check before prescribing Azathioprine/Mercaptopurine?
TPMT activity
127
How does an anal fissure present and how is it managed?
Painful, bright red bleeding
Increase water and fibre intake
Acute anal fissure - bulk forming laxatives
Chronic anal fissure - Can try topical GTN
128
Where are the majority of anal fissures?
Posterior midline
129
How do haemorrhoids present?
Rectal bleeding
Itching
May be some pain
130
How are haemorrhoids graded?
Grade I - do not prolapse out of anal canal
Grade II - prolapse on defection but reduce spontaneously
Grade III - can be manually reduced
Grade IV - cannot be reduced
131
How are haemorrhoids managed?
Increase water and fibre intake
Topical steroid cream
Rubber band ligation / surgery
132
How does an acutely thrombosed haemorrhoid present?
Significant pain
Purple oedematous perianal mass
If presents within 72 hours - excision
133
How does a perianal abscess present? What is the usual causative organism and how is it managed?
Collection of pus within the subcutaneous tissue of the anus
Pain around anus may be worse on sitting
Usually caused by E.coli
Incision+drainage
134
What is small bowel bacterial overgrowth syndrome? How does it present?
Excessive bacteria in the small bowel leads to GI syndrome
Chronic diarrhoea
Bloating and flatulence
Abdominal pain
135
How is small bowel bacterial overgrowth syndrome diagnosed?
Hydrogen breath test
136
How is small bowel bacterial overgrowth syndrome managed?
Rifaximin
137
What is Whipple's disease?
A rare systemic condition caused by Trophenyma WHipplei
Causes diarrhoea, abdominal pain and joint pain
138
What is seen on small bowel biopsy in Whipple's disease?
Acid-Schiff-positive macrophages
139
How is Whipple's disease managed?
Co-trimoxazole
140
What is Boerhaave syndrome?
Acute oesophageal rupture due to extreme vomiting
Presents as prolonged vomiting then leading to sudden onset chest pain and signs of shock
141
What are extra-intestinal features of IBD?
```
Arthritis
Erythema nodosum
Episcleritis - more common in Crohn's
Uveitis - more common in UC
Primary sclerosing cholangitis - more common in UC
```
142
Who should be given oral azathioprine to maintain remission in UC?
If they have severe UC or 2 exacerbations in the last year
143
What electrolyte abnormalities can PPIs cause?
Hyponatraemia
| Hypomagnasaemia
144
How is a perianal fistula diagnosed and managed?
MRI
Oral metronidazole
145
What is the most common hereditary condition associated with colorectal cancer? What other cancers are associated with this condition?
HNPCC (Lynch syndrome)
Endometrial cancer and gastric cancer
146
What is the familial condition with the highest risk of developing colorectal cancer? How is it monitored?
Familial adenomatous polyposis
Annual flexible sigmoidoscopy from 15 years old
147
What is the location of femoral and inguinal hernias in relation to the pubic tubercle?
Inguinal hernia = superior and medial to pubic tubercle
Femoral hernia = inferior and lateral to pubic tubercle
148
How to approximate surface area of burns?
```
Head = 9%
Whole arm = 9%
Whole leg = 9%
Front of torso = 18%
Back of torso = 18%
Hand = 1%
```
149
What is Meckel's diverticulum? How is it managed?
Congenital diverticulum of the small intestine
Often presents with painless rectal bleeding in children aged 1-2 years
Management = removal of diverticula
150
Who is screened for colorectal cancer?
Those between 60 and 74 years
| Every 2 years
151
What is the Duke's staging criteria for colorectal cancer?
Dukes A = Confined to Mucosa
Dukes B = Invading bowel wall
Dukes C = Lymph node mets
Dukes D = distant mets
152
What is the 3:6:9 rule?
On abdominal XR
Small bowel should be no more than 3cm
Colon should be no more than 6cm
Caecum should be no more than 9cm
153
How is Boerhaave syndrome diagnosed?
CT contrast swallow
