GI/general Surgery Flashcards
What is the site involvement for
A) UC
B) crohns
A) large bowel
B) entire GI tract
Where is the inflammation in
A) UC and
B) Crohns
A) UC= inflammation affects mucosa only
B) Crohns= inflammation is transmural
What are the microscopic changes in UC?
Crypt abscess formation
Reduced goblet cells
Non granulomatous
What are the microscopic features in Crohns?
Granulomatous (non caseating)
What are the macroscopic changes in UC/ Crohns?
UC= CONTINOUS inflammation (proximal from the rectum)
Pseudo polyps and ulcers may form
What are the macroscopic changes in Crohns?
Discontinous inflammation (skip lesions)
Fissures and deep ulcers (cobblestone)
Fistula
What are the features of UC?
The cardinal feature is BLOODY DIARRHOEA
This is in 90% of cases
The most common manifestation is proctitis, whereby the inflammation is confined to the rectum only- PT complain of PR bleeding and mucus discharge, increased freq and urgency of defecation and tenesmus
What are the extra intestinal manifestation of UC?
MSK- enteropathic athritis (affecting sacroiliac and other large joints) or nail clubbing)
Skin- erythema nodosim
Eyes- episcleriris, anterior uveitis, iritis
Hepatobiliary- primary sclerosing cholangitis (chronic inflammation and fibrosis of the bile ducts)
What IX would you do for UC?
FBC, U and Es, LFTs, clotting= to look for anaemia, low albumin secondary to systemic illness, evidence of inflammation (raised CRP and WCC)
Faecal calprotectin (raised in IBD, unchanged in IBS)
Stool sample for microscopy andculture
Imaging= DEFINiTIVE DIAGNOSIS for UC is colonoscopy w/ biopsy
In acute situations, then plain film abdominal radiographs or CT imaging can be used to assess for toxic megacolon and/ or the presence of bowel perforation.
How do you manage UC
- inducing remission
An acute attack will warrant aggressive fluid resuscitation, nutritional support and prophylactic heparin (due to thrombotic state of IBD flares)
Medical management to induce remission requires IV corticosteroid therapy and immunosuppresive agents, such as: ciclosporin or 5-ASA suppositories
How do you maintain remission in UC?
Remission of disease can be maintained using immunomodulators typically 5-ASAS (mesalazine/ sulfasalazine/azathioprine)
When do patients with UC require surgery?
Indications for acute surgical treatment include disease which is refractory to medical management, toxic megacolon or bowel perforation. Surgery will depend on pt and disease factors however will typically require segmental bowel resection
Total proctocolectomy is curative
What are the complications of UC?
Toxic megacolon (presents with severe abdo pain, abdo distension, pyrexia, systemic toxicity)
Colorectal carcinoma
Osteoporosis
Pouchitis (inflammation of an ileal pouch)
What are the risk factors for Crohns.
Strong family history (20% have first degree relative affected) and smoking (increases both the risk of developing crohns and relapsing)
What are the clinical features of UC?
Episodic abdominal pain and diarrhoea
Colicky in nature
Diarrhoea often contains blood/mucus
What other sites other than colon are affected in Crohns?
Oral apthous ulcers (can be painful and recurring)
Perianal disease with perianal abscess
What are the extra intestinal features of Crohns?
MSK- enteropathic arthritis, nail clubing, metabolic bone disease (secondary to malabsorption)
Skin- erythema nodosum or pyoderma
gangrenosum
Eyes- episcleritis, anterior uveitis, iritis
Renal stones
What Investigations would you do for Crohns?
Routine bloods- anaemia, low albumin (secondary to systemic illness), evidence of inflammation (raised WCC and CRP)
Faecal calprotectin
Stool sample
COLONOSCOPY w/biopsy= GOLD STaNDARD
What is used to classify severity of Crohns?
Montreal
What imaging may be used in Crohns?
CT scan Abdomen pelvis- can demonstrate bowel obstruction (from stricturing), bowel perforation, intra abdominal collections
MRI imaging- can be used to assess disease severity both with small bowel imvolvement and presence of any enteric fistulae
What is the management of Crohns?
Inducing remission- acute attacks warrant aggressive fluid rescucitation, nutritional support and prophylactic heparin and anti embolic stockings (due to the prothrombin state of IBD flares)
Medical management- corticosteroid therapy as first line, subsequent treatments including immunosuppressive agents- mesalazine, azathioprine
Maintaining remission- Azathioprine
Smoking cessation
IBD nurse specialists
If they have had it more than ten years with more than 1 segment of the bowel affected then colonoscopic surveillance is offered
What are the complications of Crohns?
Fistula, stricture, recurrent perianal fistulae, GI malignancy (small bowel cancer is 30x more common in ppl with crohns, and 3% risk of developing colorectal cancer)
Extraintestinal- malabsorption, osteporosis, increased risk of renal and gallstones
How do you diagnose IBS?
Abdominal discomfort/pain
Relieved by opening bowel
Associated with a change in bowel habit
And 2 of: abnormal stool passage, bloating, worse after eating, mucus with stools
How do you manage IBS?
General healthy diet and exercise advice:
Adequate fluid intake
Regular small meals
Reduced processed foods
Limit caffeine and alcohol
Low FODMAP diet guided by a dietitian
Trial of probiotic supplements for 4 weeks
First line management:
Loperamide for diarrhoea, laxatives for constipation (avoid lactulose), hyoscine butylbromide
What is coeliac disease?
Autoimmune condition where exposure to gluten causes an autoimmune reaction that causes inflammation in the small intestine, it usually develops in early childhood but can start at any age
What are the antibodies to remember in coeliac disease?
Anti tissue transglutaminase and anti endomysial
What is the presentation of coeliac disease?
Failure to thrive in young children
Diarrhoea
Fatigue
Weight loss
Mouth ulcers
Anaemia secondary to iron, B12 or folate deficiency
Dermatitis herpetiformia (an itchy blistering skin rash on the abdomen)
Rarely coeliac disease can present with neurological symptoms
Peripheral neuropathy
Cerebellar ataxia
Epilepsy
What is the skin presentation of coeliac?
Dermatitis herpetiformis (itchy blistering skin rash typically on the abdomen)
What should you test all new cases of type 1 diabetes for, even if they don’t have symptoms?
Coeliac disease as the conditions are often linked
What are the genetic associations with coeliac disease?
HLA-DQ2 gene (90%)
HLA- DQ8 gene
How do you diagnose coeliac?
Investigations must be carried out whilst the pt is still on a gluten diet
So you have to do the total immunoglobulin A levels before testing for the anti TTG and anti EMA antibodies, it is important to test for this as even if they are coeliac if they are IgA deficient then the antibody test will be negative
Antibodies
Anti TTG (first choice)
Anti EMA
Endoscopy and intestinal biopsy..
- crypt hypertrophy
- villous atrophy
What are the associations with coeliac disease?
T1DM Thyroid disease Autoimmune hepatitis Primary biliary cirrhosis Primary sclerosing cholangitis
What are the complications with untreated coeliac disease?
Vitamin deficiency Anaemia Osteoporosis Ulcerative jejunitis Non hodgkin lymphoma Small bowel adenocarcinoma (rare)
What are the signs of liver disease?
Jaudice Hepatomegaly Spider naevi Palmar erythema Gynaecomastia Bruising Asterixis Ascites Caput medusae(engorged superficial epigastrix veins)
What investigations would you do for liver disease?
FBC- show raised MCV
LFTS- show elevated ALT and AST
Particularly raised GAMMA GT
ALP raised later in the disease
Low albumin due to reduced synthetic function
Elevated bilirubin due to cirrhosis
Clotting time increased (increased prothrombin time)
U and Es elevated in hepatorenal syndrome
US- increased echogenicity
Fibroscan
Liver biosy can be used to confirm alcohol related hepatitis or cirrhosis
How do you manage alcoholic liver disease?
Steroids improve short term outcomes, but no long term
Stop drinking alcohol immediately
Consider a detoxification regime
Nutritional support with vitamins (particularly thiamine) and a high protein diet
Referall for liver transplant in severe disease (must abstain from alcohol for 3 months)
What are the symptoms of alcohol withdrawal?
6-12 hours- tremor, sweating, headache, craving, anxiety
12-24- hallucination
24-48- seizures
24-72 hrs- delirium tremens
What is delirium tremens?
A medical emergency associated with alcohol withdrawal, has a mortality of 35% if left untreated
What is the presentation of delirium tremens?
Acute confusion Severe agitation Delusions and hallucinations Tremor Tahycardia Hypertension Hyperthermia Ataxia Arrythmia
How do you manage alcohol withdrawal?
CIWA- Ar can be used to score the pt on their withdrawal symptoms and guide treatment
Chlordiazepoxide is a benzodiazepine used to combat the effects of alcohol withdrawal
IV high dose B vitamins (pabrinex)
What is Liver cirrhosis?
Result of chronic inflammation and damage to liver cells, when the liver cells are damaged they are replaced with fibrosis and nodules of scar tissue form within the liver. This is called portal hypertension.
What are the causes of liver cirrhosis?
Alcoholic liver disease
Non alcoholic fatty liver disease
Hep B
Hep C
What are the signs of Liver disease?
Jaundice Hepatomegaly Splenomegaly Palmar erythema Gynaecomastia Bruising Ascites Caput medusae Asterixis
What Ix would you do for Liver cirrhosis?
Liver biochemistry is often normal, however in decompensated cirrhosis all of the markers (ALT, AST, ALP, bilirubin) become deranged
Albumin and prothrombin are useful markers of the synthetic function of the liver. The albumin level drops and the prothrombin time increases as the synthetic function becomes worse.
AFP for hepatocellular carcinoma is checked every 6 months
Hyponatraemia Indicates fluid retention in severe liver disease
Urea and creatinine deranged in hepatorenal syndrome
Enhanced liver fibrosis (ELF) is the first line for assesing cirrhosis in non alcoholic fatty liver disease
Ultrasound scan
Fibroscan (checks for cirrhosis, and measures the elasticity of the liver)
How do you perform a stoma exam?
Check the pt see if they are well/hydrated/? Any signs of malnutrition?
Abdomen- any signs of acute abdomen/obstruction, scar from operation?
In terms of the stoma you want to look at the site, the surrounding skin and the opening
If the opening is sprouted= ileostomy
If the opening is flush with skin= colostomy
You need to look at the contents
If liquid= ileostomy
If solid= colostomy
Urine= urostomy
Palate around the stoma
What are the different types of colostomy?
End colostomy
Loop colostomy
Double barrel colostomy
When is an end colostomy used?
Hartmanns can be used in bowel obstruction, inflammation, contamination where primary anastomosis is unfavourable, emergency resection of rectosigmoid lesions
AP resection for low rectal tumours (all distal bowel removed so permanent colostomy is required)
When is a double barrel colostomy used?
Double barrel colostomy- segment of bowel removed and both ends are brought to the surface. The proximal end drains farces and the distal drains mucous
When is a urostomy used?
After bladder cancer, it uses ileum to attach to ureters and skin
What are the early complications of stoma?
High output stoma (>1L/day) this leads to dehydration and hypokalaemia, retraction, bowel obstruction/ileus, ischaemia of stom
Late: parastomal hernia, prolapse, fistulae, stenosis, psychological complications, skin dermatitis, malnutrition
What should the initial diet for stoma care be?
Low fibre for first two months
What is a hartmanns procedure?
Removal of the rectosignmoid colon with closure of the anorectal stump and formation of a colostomy
Why is analgesia important post op?
Encourages the pt to mobilise, ventilate their lungs fully and have adequate oral intake
When is NSAIDS (ibuprofen) contraindicated?
In asthma, renal impairment, heart disease and stomach ulcers.
What do you need to use in opioid induced respiratory depression?
Naloxone infusion
What can you give for bradycardia induced by analgesia?
Atropine
What are the risk factors for post op nausea?
Female History of motion sickness or previous PONV Non smoker Use of post op opiates Younger age Use of volatile anaesthetics
How can you prevent PONV from occuring?
Normally antiemetic is given at the end of the procedure by the anaesthetist
Ondansetron (5HT3 receptor antagonist)- avoided in patients at risk of prolonged QT interval
Dexamethasone- used with caution in diabetic or immunocompromised pts
Cyclizine- caution with HF/Elderly
Catheters post surgery are usually removed when the patient can mobilise to the toilet, what is this period called?
Removal pf catheter is a trial without catheter. it is called this as there is a risk the patient will find it difficult to pass urine normally and go into urinary retention, the catheter may need to be reinserted again for a period before removal can be tried again.
What is a PEG tube?
A tube from the surface of the abdomen to the stomach
What does total parenteral nutrition involve?
This involves meeting the full ongoing nutritional requirements of the pt using an IV infusion of a solution of carbs, fats, proteins, vitamins and monerals. TP; is very irritant to veins and can cause thrombophlebitis, so its normally given through a central line rather than peripheral cannula.
What are the complications that can occur in the post operative period?
Anaemia Atelectasis (portion of the lung collapses due to under ventilation) Infections Wound dehiscence Ileus Haemorrhage DVT/PE Shock- due to hypovolaemia, sepsis or heart failure Arrythmias- AF ACS AKI Urinary retention Delirium
A post of full blood count is used to measure the haemoglobin, what should you do if there is anaemia present?
As a rough guidance;
Hb under 100g/L - start an oral iron (ferrous sulphate 200mg three times daily for three months)
Hb under 70-80g/l- blood transfusion in addition to oral iron
What are the signs of hypovolaemia (inadequate fluid)?
Hypotension (systolic <100mmHg) Tachycardia (heart rate >90) Capillary refill time >2 seconds Cold peripheries Raised respiratory rate Dry mucous membranes Reduced skin turgor Reduced urine output Sunken eyes Reduced body weight from baseline Feeling thirsty
What are the signs of fluid overload?
Peripheral oed3ma (check ankles and sacral area) Pulmonary oedema (SOB, reduced oxygen sats, raised resp rates and bibasal crackles) Raised JVP Increased body weight from baseline (regular weights are an important way of monitoring fluid balance)
What is third spacing and what is the signs?
Third spacing refers to fluid shifting into the non functional third space (interstitium), often this refers to the development of oedema
What is appendicitis?
Inflammation of the appendix
What is the appendix?
A small, thin tube arising from the caecum.
What are the signs and symptoms of appendicitis?
Central abdominal pain that moves down to the right iliac fossa within the first 24 hours
Eventually becoming localised in the RIF.
Loss of appetite
Nausea and vomiting
Low grade fever
Rosvings (palpation on the LIF causing pain in the RIF)
Guarding on abdo palpation
Rebound tenderness in the RIF
Percussion tenderness
Rebound tenderness and percussion tenderness suggest peritonitis, potentially indicating a ruptured appendix.
How is appendicitis diagnosed?
Mostly a clinical diagnosis
Can use USS (kids, women), CT
Diagnostic laparoscopy if clinical presentation indicates appendicitis but investigations are negative
What should be your first thought in woman with acute abdo pain?
Pregnancy
What is mesenteric adenitis?
Describes inflamed abdominal lymph nodes, it presents with abdominal pain, usually in younger children. Often associated with tonsilitis or URTI. No spec treatment needed
What is meckels diverticulum?
Malformation of the distal ileum, occurs in around 2% of the population. It is usually asymptomatic and does not require any treatment. However it can bleed, beckme inflamed, rupture or cause a volvulus or intussusception.
What are the complications of appendicectomy?
Bleeding Infection VTE Pain Scars Damage to bowel, bladder or other organs Anaesthetic risks
What are the causes of bowel obstruction?
Adhesions (small bowel), hernias (small bowel), malignancy (large bowel)
Volvulus (large bowel)
Diverticular disease
Strictures ie: secondary to crohns
Intussusception
What should you ask about obstruction?
Hernias, change in bowel habit, weight loss, PR bleeding (bowel cancer), previous surgery
What are the main causes of intestinal adhesions?
Abdo or pelvic surgery
Peritonitis
Abdominal or pelvic infections
Endometriosis
What are the clinical features of bowel obstruction?
Vomiting (particularly green bilious vomiting)
Abdo distension
Diffuse abdo pain
Absolute constipation and lack of flatulence
Tinkling bowel sounds- may be heard in early bowel obstruction
Abdo x ray Upper limits of the normal diameter of bowel; 3cm small bowel 6cm colon 9cm caecum
What is the difference between valvulae conniventes and haustra?
Valvulae conniventes
= present in the small bowel and mucosal folds that form lines extending the full width of the bowel
Haustra= do not extend the full width of the bowel p, seen on x ray as lines that extend only part of the way across the bowel
What are the problems with bowel obstruction?
Hypovolemic shock
Bowel ischaemia
Bowel perforation
Sepsis
What key things are you looking for with bowel obstruction?
Electrolyte imbalances
Metabolic alkalosis due to stomach acid (VBG)
Bowel ischaemia (raised lactate- either on VBG or lab sample)
What is the management of bowel obstruction?
NBM
IV fluids
NG tube with free drainage to allow stomach contents to freely drain an reduce the risk of vomiting and aspiration
AXR may be initial but may be skipped and contrast abdo CT scan done which is required to confirm
Erect CXR- pneumoperitonejm
Laparoscopy/ Laparotomy may be the definitive management if conservative failed
What is ileus?
This is a condition affecting the small bowel, where the normal peristalsis that pushes the contents along the length of the intestines temporarily stops, it may be referred to as paralytic ileus or adynamic ileus.
What is pseudo obstruction?
Functional obstruction of the large bowel, pts present with intestinal obstruction but no mechanical cause is found. Less common than ileus affecting the small bowel.
What are the causes of ileus?
Injury to the bowel
Handling of the bowel during surgery
Inflammation or infection in, or nearby the bowel
Electrolyte imbalance (hypokalaemia, hyponatraemia)
What should you think of in a pt with a recent abdo surgery, hyponatraemia and hypokalaemia, unopened bowels?
Ileus
What is the presentation of ileus?
Same as BO
What is the management of ileus?
NBM NG tube if vomiting IV fluids Mobilisation to help stimulate Total parenteral nutrition may be required whilst awaiting for the bowel to regain function
What is a volvulus?
This is a condition where the bowel twists around itself an the mesentery it’s attached to
Twisting in the bowel leads to a closed-loop bowel obstruction, where a section of bowel is isolated by obstruction on either side.
The blood vessels that supply the bowel can be involved, cutting off the blood supply to the bowel, which leads to bowel ischaemia. Ischaemia leads to death of the bowel tissue (necrosis), and bowel perforation.
What are the types of volvulus?
Sigmoid volvulus
Caecal volvulus
What are the risk factors for volvulus?
Neuropsychiatric disorders- parkinsons Nursing home residents Chronic constipation High fibre diet Pregnancy Adhesions
What is the presentation of bowel obstruction?
Signs and symptoms are same ad bowel obstruction;
Vomiting (particularly green bilious vomiting)
Abdominal distention
Diffuse abdominal pain
Absolute constipation and lack of flatulence
What is the diagnosis of volvulus?
Abdominal x-ray can show the “coffee bean” sign in sigmoid volvulus, where the dilated and twisted sigmoid colon looks like a giant coffee bean.
A contrast CT scan is the investigation of choice to confirm the diagnosis and identify other pathology.
What is the management of volvulus?
The initial management is the same as with bowel obstruction (nil by mouth, NG tube and IV fluids).
Conservative management with endoscopic decompression can be attempted in patients with sigmoid volvulus (without peritonitis). A flexible sigmoidoscope is inserted carefully, with the patient in the left lateral position, resulting in a correction of the volvulus. A flatus tube / rectal tube is left in place temporarily to help decompress the bowel and is later removed. There is a risk of recurrence (around 60%).
Surgical management involves:
Laparotomy (open abdominal surgery)
Hartmann’s procedure for sigmoid volvulus (removal of the rectosigmoid colon and formation of a colostomy)
Ileocaecal resection or right hemicolectomy for caecal volvulus
What are the complications of hernias you need to be wary of?
Incarcentation
Strangulation
Obstruction
What are the management options of hernias?
Conservative- pts with a wide neck, not good candidates for surgery
Mesh repair (tension free pair)
Tension repair
How can you distinguish between indirect and direct inguinal hernia?
There is a specific finding of indirect inguinal hernias that help you differentiate them from a direct inguinal hernias. When an indirect hernia is reduced and pressure is applied (with two fingertips) to the deep inguinal ring (at the mid-way point from the ASIS to the pubic tubercle), the hernia will remain reduced.
What is a hiatus hernia?
Protrusion of an organ from the abdominal cavity into the thorax through the oesophageal hiatus. This is typically the stomach herniating although rarely small bowel, colon or mesentery can herniate through.
What is the surgical treatment of hiatus hernia?
Laparoscopic fundoplication (if high risk of complications or symptoms are resistant to medical treatment)
What are haemorrhoids, what are the associations, symptoms, treatment?
Enlarged anal vascular cushions, it is mot clear why they become enlarged and swollen but they are often associated with constipation, straining, pregnancy, obesity, increased age, increased intra abdominal pressure- weight lifting, chronic coughing
A common presentation is with painless, bright red bleeding, typically on the toilet tissue or seen after opening the bowels. The blood is not mixed with the stool (this should make you think of an alternative diagnosis).
Other symptoms include:
Sore / itchy anus
Feeling a lump around or inside the anus
Proctoscopy is required for proper visualisation and inspection
Management
Topical treatments can be given for symptomatic relief and to help reduce swelling, for example:
Anusol (contains chemicals to shrink the haemorrhoids – “astringents”) Anusol HC (also contains hydrocortisone – only used short term) Germoloids cream (contains lidocaine – a local anaesthetic) Proctosedyl ointment (contains cinchocaine and hydrocortisone – short term only)
What is diverticulosis?
What are the risk factors?
How is it diagnosed
What is the management?
The most commonly affected section of the bowel is the sigmoid colon, however it can affect the entire large intestine in some people
Increased age
Low fibre diets
Obesity
NSAID use
Often diagnosed incidentally on colonoscopy or CT scans
Treatment is not necessary where the patient is asymptomatic, however advice regarding a high fibre diet and weight loss is appropriate
Diverticulosis may cause lower left abdo pain, constipation or rectal bleeding
Management is with increased fibre in diet and bulk forming laxatives- isphaghula husk
Stimulant laxatives- ie: senna, should be avoided
Surgery to remove the affected area may be required where there are significant symptoms
What is acute diverticulitis and what ate the symptoms?
Inflammation of the diverticula
Pain and tenderness in the left iliac fossa / lower left abdomen
Fever
Diarrhoea
Nausea and vomiting
Rectal bleeding
Palpable abdominal mass (if an abscess has formed)
Raised inflammatory markers (e.g., CRP) and white blood cells
How do you treat acute diverticulitis which is uncomplicated?
Oral co-amoxiclav (at least 5 days)
Analgesia- avoiding NSAIDS and opiates
Only taking clear liquids (avoiding solid food) until symptoms improve (usually 2-3 days)
Follow up within 2 days to review symptoms
How do you treat pts with diverticulitis who have severe pain or complications?
Require admission to hospital
- NBM/ clear fluids only
- IV abx
- IV fluids
- analgesia
- CT scan
- urgent surgery may be required for complications
What are the complications of acute diverticulitis?
Perforation Peritonitis Peridiverticular abscess Large haemorrhage requiring blood transfusions Fistula Ileus/obstruction
What does the foregut comprise of and what is the blood supply?
Stomach, part of the duodenum, biliary system, liver, pancreas and spleen
Coeliac artery
What is the midgut and what is that supplied by?
From the distal part of the duodenum to the first half of the transverse colon
Supplied by the superior mesenteric artery
What is the hindgut?
This is from the second half of the transverse colon to the rectum, this is supplied by the inferior mesenteric artery
What is chronic mesenteric ischaemia?
This is also known as intestinal angina, it is the result of narrowing of the mesenteric blood vessels by atherosclerosis
Results in intermittent abdominal pain, when the blood supply cannot keep up with the demand.
What is the typical presentation of chronic mesenteric ischaemia?
Classic triad of…
1) central colicky abdo pain after eating (starting around 30 minutes after eating and lasting 1-2 hours)
2) Weight loss due to avoiding food which causes pain
3) abdominal bruit may be heard on auscultation
What are the risk factors for chronic mesenteric ischaemia?
Same as any other cardiovascular disease… Increased age Family history Smoking Diabetes Hypertension Raised cholesterol
How do you diagnose chronic mesenteric ischaemia?
CT angiography
What is the treatment of chronic mesenteric ischaemia?
Management involves:
Reducing modifiable risk factors (e.g., stop smoking) Secondary prevention (e.g., statins and antiplatelet medications) Revascularisation to improve the blood flow to the intestines
Revascularisation may be performed by:
Endovascular procedures first-line (i.e. percutaneous mesenteric artery stenting) Open surgery (i.e endarterectomy, re-implantation or bypass grafting)
What causes acute mesenteric ischaemia?
Typically caused by a rapid blockage in blood flow through the superior mesenteric artery
Usually caused by a thrombus stuck in the atery, blocking blood flow or an embolus.
What is a key risk factor of acute mesenteric ischaemia?
Atrial fibrillation- thrombus forms in the left atrium, then mobilises (thromboembolism) down the aorta to the superior mesenteric artery where it becomes stuck and cuts off blood supply.
What does acute mesenteric ischaemia present with?
Acute non specific abdominal pain
The pain is disproportionate to the examination findings.
Pts can go on to develop shock, peritonitis and sepsis
Over time the ischaemic to the bowel will result in necrosis of the bowel tissue and perforation
What is the diagnostic test of choice for acute mesenteric ischaemia?
Contrast CT
Allowing radiologist to assess both the bowel and the blood supply
Patients will have metabolic acidosis and raised lactate level due to ischaemia
How do you treat acute mesenteric ischaemia?
Patients require surgery to achieve two objectives:
Remove necrotic bowel
Remove or bypass the thrombus in the blood vessel (open surgery or endovascular procedures may be used)
There is a very high mortality (over 50%) with acute mesenteric ischaemia.
What are the risk factors of colorectal cancer?
FHx of bowel cancer Familial adenomatous polyposis Hereditary nonpolyposis colorectal carcinoma (HNPCC), also known as Lynch syndrome IBD (Crohns/UC) Increased age Diet (high in red and processed meat, low in fibre) Obesity and sedentary lifestyle Smoking Alcohol
What is FAP?
Familial adenomatous polyposis
Autosomal dominant condition involving malfunctioning of the tumour suppressor genes- adenomatous polyposis coli. It results in many polyps (adenomas) developing along the large intestine. These polyps have the potential to become cancerous (usually before the age of 40). Pts can have a panproctocolectomy to prevent the development of bowel cancer.
What is HNPCC?
Hereditary non polyposis colorectal cancer, also known as lunch syndrome. It is an autosomal dominant condition which results from mutations in the DNA mismatch repair (MMR), patients are at a higher risk of a number of cancers but particularly colorectal cancer.
What are the red flags that should make you consider bowel cancer?
Change in bowel habit- usually to more loose and frequent stools
Unexplained weight loss
Rectal bleeding
Unexplained abdominal pain
Iron deficiency anaemia (microcytic anaemia with low ferritin)
Abdominal or rectal mass on examination
What is the two week wait urgent cancer referral for bowel cancer?
Over 40 years with abdominal pain and unexplained weight loss
Over 50 years with unexplained rectal bleeding
Over 60 years with a change in bowel habit or iron deficiency anaemia
What is a FIT test?
Faecal immunochemical test and bowel cancer screening
In England, people aged 60-74 years are sent a home FIT test to do every 2 years, if results come back positive they are sent for a colonoscopy.
FIT test measures the amount of Haemoglobin in stool.
What investigations are done for colorectal cancer?
Colonoscopy w/ biopsy for suspicious lesions
Sigmoidoscopy involves an endoscopy if the rectum and sigmoid colon only, this may be used in cases where the only feature is rectal bleeding.
CT colonography
CT scan with bowel prep and contrast to visualise the colon in more detail
This may be considered in patients less for fit for a colonoscopy but it is less detailed and does not allow for a biopsy
Staging CT to look for CT TAP
What is CEA?
Carcinoembryonic antigen= a tumour marker blood test for bowel cancer, this is not helpful in screening but it used for predicting relapse in pts previously treated for bowel cancer.
What is the staging score used for bowel cancer?
TNM classification
What is the management of colorectal cancer?
Surgical resection
Chemotherapy
Radiptherapy
Palliative care
What are the surgery options for bowel cancer?
Laparoscopic surgery (where possible) generally gives better recovery and fewer complications compared with open surgery. Robotic surgery is increasingly being used, which is essentially a more advanced laparoscopic procedure.
Surgery involves:
Identifying the tumour (it may have been tattooed during an endoscopy)
Removing the section of bowel containing the tumour,
Creating an end-to-end anastomosis (sewing the remaining ends back together)
Alternatively creating a stoma (bringing the open section of bowel onto the skin)
What is low anterior section syndrome?
Low anterior resection syndrome may occur after resection of a portion of bowel from the rectum, with anastomosis between the colon and rectum. It can result in a number of symptoms, including:
Urgency and frequency of bowel movements
Faecal incontinence
Difficulty controlling flatulence
What are the complications of gallstones?
Pancreatitis Acute cholecystitis Acute cholangitis Bouverets Gallstone ileus
What are the risk factors for gallstones?
Fat, fair, forty, female
What is the presentation of gallstones?
Biliary colic
Severe, colicky epigastric or right upper quadrant pain
Often triggered by meals (particularly high fat meals)
Lasting between 30 minutes and 8 hours
May be associated with nausea and vomiting
Why does biliary colic occur?
Fat entering the digestive system causes cholecystokinin (CCK) secretion from the duodenum. CCK triggers contraction of the gallbladder, which leads to biliary colic. Patients with gallstones and biliary colic are advised to avoid fatty foods to prevent CCK release and gallbladder contraction. Exams may test this mechanism, so it is worth remembering.
What Liver function tests are done for gallstones?
Bilirubin normally drains from the liver, through the bile ducts and into the intestines. Raised bilirubin (jaundice) with pale stools and dark urine represents an obstruction to flow within the biliary system. Obstruction may be caused by a gallstone in the bile duct or an external mass pressing on the bile ducts (e.g., cholangiocarcinoma or tumour of the head of the pancreas).
ALP
ALT
AST
(ALT and AST are enzymes produced in the liver, they are helpful as markers of hepatocellular injury- damage to liver cells)
In patients with cholestasis (due to gallstones)
, ALT and AST can increase slightly with a higher rise in ALP (obstructive picture)
If ALT and AST are high compared with the ALP level, this is more indicative of problem inside the liver with hepatocellular injury (a hepatitic picture)
Basically if ALP high= obstruction
If ALT/AST higher= hepatic problem
What is the first line investigation needed for gallstones?
Ultrasound scan
What is the MRCP used for?
An MRI scan that produces a detailed image of the biliary system, it is very specific and sensitive for biliary tree disease, such as: stones in the bile duct And malignancy.
MRCP is usually used when the US does not show stones in the duct but there is bile duct dilatation or raised bilirubin suggestive of obstruction.
When are ERCPs used?
The main indication for ERCP is to clear stones in the bile ducts
Inject contrast and take x-rays to visualise the biliary system and diagnose pathology (e.g., stones or strictures)
Perform a sphincterotomy on the sphincter of Oddi if it is dysfunctional (blocking flow)
Clear stones from the ducts
Insert stents to improve bile duct drainage (e.g., with strictures or tumours)
Take biopsies of tumours
What are the key complications of ERCP?
Excessive bleeding
Cholangitis
Pancreatitis
When would you use CT scans for biliary system?
Less useful for looking at the biliary system and gallstones, they may be used to look for differential diagnosis- pancreatic head tumour and complications like perforation and abscesses.
What is the management of gallstones?
Asymptomatic patients with gallstones may be treated conservatively, with no intervention required.
Patients with symptoms or complications of gallstones are treated with cholecystectomy, which is surgical removal of the gallbladder (provided they are fit for surgery).
Cholecystectomy
Cholecystectomy involves surgical removal of the gallbladder. It is indicated where patients are symptomatic of gallstones, or the gallstones are leading to complications (e.g., acute cholecystitis). Stones in the bile ducts can be removed before (by ERCP) or during surgery.
Laparoscopic cholecystectomy (keyhole surgery) is preferred to open cholecystectomy (with a right subcostal “Kocher” incision), as it has less complications and a faster recovery.
Complications of cholecystectomy include:
Bleeding, infection, pain and scars
Damage to the bile duct including leakage and strictures
Stones left in the bile duct
Damage to the bowel, blood vessels or other organs
Anaesthetic risks
Venous thromboembolism (deep vein thrombosis or pulmonary embolism)
Post-cholecystectomy syndrome
What is post cholecystectomy syndrome?
Group of non spefici symptoms that can occur after a cholecystectomy. They may be attributed to changes in bile flow after removal of the gallbladder, symptoms include…
1) diarrhoea
2) indigestion
3) epigastric or RUQ pain or discomfort
4) nausea
5) intolerance of fatty foods
6) flatulence
What is acute cholecystitis?
Inflammation of the gallbladder, which is caused by blockage of the cystic duct preventing the gallbladder from draining.
What is the presentation of acute cholecystitis?
The main presenting symptom of cholecystitis is pain in the right upper quadrant (RUQ). This may radiate to the right shoulder.
Other features include:
Fever
Nausea
Vomiting
Tachycardia (fast heart rate) and tachypnoea (raised respiratory rate)
Right upper quadrant tenderness
Murphy’s sign
Raised inflammatory markers and white blood cells
What is murphys sign?
This is suggestive of acute cholecystitis
This is where you place a hand in RUQ and apply pressure
Ask the patient to take a deep breath in
The gallbladder will move downwards during inspiration and come in contact with your hand
Stimulation of the inflamed gallbladder results in acute pain and sudden stopping of inspiration
What imaging would you do for acute cholecystitis?
The first step is an abdominal ultrasound scan. Signs of acute cholecystitis on ultrasound are:
Thickened gallbladder wall
Stones or sludge in gallbladder
Fluid around the gallbladder
Magnetic resonance cholangiopancreatography (MRCP) may be used to visualise the biliary tree in more detail if a common bile duct stone is suspected but not seen on an ultrasound scan (e.g., bile duct dilatation or raised bilirubin).
What is the management of acute cholecystitis?
Patients with suspected acute cholecystitis need emergency admission for investigations and management.
Conservative management involves:
Nil by mouth
IV fluids
Antibiotics (as per local guidelines)
NG tube if required for vomiting
Endoscopic retrograde cholangio-pancreatography (ERCP) can be used to remove stones trapped in the common bile duct.
Cholecystectomy (removal of the gallbladder) is usually be performed during the acute admission, within 72 hours of symptoms. In some cases, it may be delayed for 6-8 weeks after the acute episode to allow the inflammation to settle.
What are the complications of cholecystitis?
Sepsis
Gallbladder empyema
Gangrenous gallbladder
Perforation
What is a gallbladder empyema?
Gallbladder empyema refers to infected tissue and pus collecting in the gallbladder. Management involves IV antibiotics and one of two main options:
Cholecystectomy (to remove the gallbladder)
Cholecystostomy (inserting a drain into the gallbladder to allow the infected contents to drain)
What is acute cholangitis?
Acute cholangitis is infection and inflammation in the bile ducts. It is a surgical emergency and has a high mortality due to sepsis and septicaemia.
What are the two main causes of acute cholangitis?
Obstruction in the bile ducts stopping bile flow (i.e. gallstones in the common bile duct)
Infection introduced during an ERCP procedure
What are the most common organisms of acute cholangitis?
Eschericia coli
Klebsiella species
Enterococcus species
What is charcots triad?
Acute cholangitis presents with charcots triad, this is:
Right upper quadrant pain
Fever
Jaundice (raised bilirubin)
What is the management of acute cholangitis?
Patients with suspected acute cholangitis need emergency admission for investigations and management.
Patients need acute management of sepsis and acute abdomen, including:
Nil by mouth IV fluids Blood cultures IV antibiotics (as per local guidelines) Involvement of seniors and potentially HDU or ICU
How do you diagnose common bile duct stones and cholangitis?
Abdominal ultrasound scan
CT scan
Magnetic resonance cholangio-pancreatography (MRCP)
Endoscopic ultrasound
(Least to most sensitive)
What is cholangiocarcinoma and what are the risk factors?
Adenocarcinoma that affects the bile ducts inside the liver (intrahepatic) or outside the liver (extrahepatic)
Key risk factors
Primary sclerosing cholangitis (UC are at risk of developing primary sclerosing cholangitis)
Liver flukes
What is the presentation of adenocarcinoma?
Obstructive jaundice is the key presenting feature to remember. Obstructive jaundice is also associated with:
Pale stools
Dark urine
Generalised itching
Other non-specific signs and symptoms include:
Unexplained weight loss
Right upper quadrant pain
Palpable gallbladder (swelling due to an obstruction in the duct distal to the gallbladder)
Hepatomegaly
What would you suspect if painless jaundice or palpable gallbladder?
Courvoisier’s law states that a palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic cancer.
TOM TIP: Painless jaundice should make you think of cholangiocarcinoma or cancer of the head of the pancreas. Pancreatic cancer is more common, so this is likely the answer in your exams.
What is the tumour marker for cholangiocarcinoma?
CA19-9
What investigations would you do for cholangiocarcinoma?
Diagnosis is based on imaging (CT or MRI) plus histology from a biopsy.
Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP). This is used to look for metastasis and other cancers.
CA 19-9 (carbohydrate antigen) is a tumour marker that may be raised in cholangiocarcinoma. It is also raised in pancreatic cancer and a number of other malignant and non-malignant conditions.
Magnetic resonance cholangio-pancreatography (MRCP) may be used to assess the biliary system in detail to assess the obstruction.
Endoscopic retrograde cholangio-pancreatography (ERCP) can be used to put a stent in and relieve the obstruction, and also obtain a biopsy from the tumour.
What is the management of cholangiocarcinoma?
Management will be decided at a multidisciplinary team (MDT) meeting.
Curative surgery may be possible in early cases. It may be combined with radiotherapy and chemotherapy.
In most cases, curative surgery is not possible. Palliative treatment may involve:
Stents inserted to relieve the biliary obstruction
Surgery to improve symptoms (e.g., bypassing the biliary obstruction)
Palliative chemotherapy
Palliative radiotherapy
End of life care with symptom control
What type of cancer is pancreatic cancer normally and where does it normally occur?
Adenocarcinoma
Head of the pancreas
Once a tumour in the head of the pancreas grows large enough it can compress the bile ducts, resulting in obstructive jaundice
Where do pancreatic cancers usually spread to?
Pancreatic cancers tend to spread and metastasise early, particularly to the liver, then to the peritoneum, lungs and bones. The average survival, when diagnosed with advanced disease, is around 6 months.
When caught early, the cancer is isolated to the pancreas and surgery is possible, the 5-year survival is still around 25% or less.
What is the presentation of pancreatic cancer?
Very similar to cholangiocarcinoma
Painless obstructive jaundice is a key presenting feature that should make you immediately consider pancreatic cancer (the key differential is cholangiocarcinoma). This occurs when a tumour at the head of the pancreas compresses the bile ducts, blocking the flow of bile out of the liver. It presents with:
Yellow skin and sclera
Pale stools
Dark urine
Generalised itching
The other presenting features for pancreatic cancer can be vague:
Non-specific upper abdominal or back pain
Unintentional weight loss
Palpable mass in the epigastric region
Change in bowel habit
Nausea or vomiting
New‑onset diabetes or worsening of type 2 diabetes
What should you suspect if you have a patient with new onset diabetes or worsening type 2 diabetes?
TOM TIP: It is worth noting that a new onset of diabetes, or a rapid worsening of glycaemic control type 2 diabetes, can be a sign of pancreatic cancer. Keep pancreatic cancer in mind if a patient in your exams or practice has worsening glycaemic control despite good lifestyle measures and medication.
What is the scenario where GPs can refer directly for a CT scan?
Pancreatic cancer
What is the NICE guidelines for suspected pancreatic cancer?
The NICE guidelines on suspected cancer (last updated January 2021) give the criteria for when to refer for suspected pancreatic cancer:
Over 40 with jaundice – referred on a 2 week wait referral
Over 60 with weight loss plus an additional symptom (see below) – referred for a direct access CT abdomen
The NICE guidelines suggest a GP referral for a direct access CT abdomen (or ultrasound if not available) to assess for pancreatic cancer if a patient has weight loss plus any of:
Diarrhoea Back pain Abdominal pain Nausea Vomiting Constipation New‑onset diabetes
What is courvoisiers law?
Courvoisier’s law states that a palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic cancer.
What is trousseaus sign of malignancy?
Trousseau’s sign of malignancy refers to migratory thrombophlebitis as a sign of malignancy, particularly pancreatic adenocarcinoma. Thrombophlebitis is where blood vessels become inflamed with an associated blood clot (thrombus) in that area. Migratory refers to the thrombophlebitis reoccurring in different locations over time.
What investigations need to be done for pancreatic cancer?
Diagnosis is based on imaging (usually CT scan) plus histology from a biopsy.
Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP). This is used to look for metastasis and other cancers.
CA 19-9 (carbohydrate antigen) is a tumour marker that may be raised in pancreatic cancer. It is also raised in cholangiocarcinoma and a number of other malignant and non-malignant conditions.
Magnetic resonance cholangio-pancreatography (MRCP) may be used to assess the biliary system in detail to assess the obstruction.
Endoscopic retrograde cholangio-pancreatography (ERCP) can be used to put a stent in and relieve the obstruction, and also obtain a biopsy from the tumour.
Biopsy may be taken through the skin (percutaneous) under ultrasound or CT guidance, or during an endoscopy under ultrasound guidance.
What is the management of pancreatic cancer?
Surgery
?whipples procedure- pancreaticduodenectomy only for cases that are confined to head of pancreas
Palliative care
What are the 3 important causes of pancreatitis to remember?
I – Idiopathic G – Gallstones E – Ethanol (alcohol consumption) T – Trauma S – Steroids M – Mumps A – Autoimmune S – Scorpion sting (the one everyone remembers) H – Hyperlipidaemia E – ERCP D – Drugs (furosemide, thiazide diuretics and azathioprine)
What is the presentation of acute pancreatitis?
Epigastric pain, radiating to back
Nausea
Vomiting
Systemically unwell (low grade fever and tachy)
What investigations can be done for pancreatitis?
FBC (WCC)
U and Es
LFTs (for transaminases and albumin)
Calcium
ABG (For PaO2 and blood glucose)
Amylase is raised more than 3x the upper limit of normal in acute pancreatitis
In chronic pancreatitis it may not rise because the pancreas has reduced function
CRP
Ultrasound is the Ix of choice for assessing gallstones
CT abdomen can assess for complications of pancreatitis (necrosis, abscesses, fluid collections) it is not usually required unless complications are suspected (eg: the pt is becoming more unwell)
What scoring system can be used for acute pancreatitis?
GLASGOW SCORE
0 or 1= mild pancreatitis
2= moderate pancreatitis
3 or more= severe pancreatitis
What is the criteria for Glasgow score?
PANCREAS
P= PaO2 <8KPa A= Age >55 N= neutrophils (WBC>15) C= Calcium <2 R= uRea >16 E= enzymes (LDH >600 or AST/ALT) A= Albumin <32 S= sugar (Glucose >10)
What is the management of acute pancreatitis?
Patients with acute pancreatitis can become very unwell rapidly. They require admission to supportive management. Moderate or severe cases should be considered for management on the high dependency unit (HDU) or intensive care unit (ICU).
Management involves:
Initial resuscitation (ABCDE approach)
IV fluids
Nil by mouth
Analgesia
Careful monitoring
Treatment of gallstones in gallstone pancreatitis (ERCP / cholecystectomy)
Antibiotics if there is evidence of a specific infection (e.g., abscess or infected necrotic area)
Treatment of complications (e.g., endoscopic or percutaneous drainage of large collections)
Most patients will improve within 3-7 days.
What are the complications of acute pancreatitis?
Necrosis of the pancreas Infection in a necrotic area Abscess formation Acute peripancreatic fluid collections Pseudocysts (collections of pancreatic juice) can develop 4 weeks after acute pancreatitis Chronic pancreatitis
What is chronic pancreatitis?
Chronic inflammation in the pancreAs
It results in fibrosis and reduced function in the pancreatic tissue
Alcohol is the most common cause
Presents similar to acute pancreatitis, but generally less intense and longer lasting
What are the key complications of chronic pancreatitis?
Chronic epigastric pain
Loss of endocrine functions (diabetes)
Lack of exocrine function (lack of pancreatic enzymes- particularly lipase, secreted into the GI tract)
Damage and strictures to the duct system, resulting in obstruction in the excretion of the pancreatic juice and bile
Formation of pseudocysts and abscesses
What is the management of chronic pandreatitis?
Abstinence from smoking and alcohol is important in managing symptoms and complications
Analgesia can be used to manage the pain, although it can be severe and difficult to manage.
Replacement pancreatic enzymes (creon) may be required if there is a loss of pancreatic enzymes (ie:
Iipase, otherwise a lack of enzymes leads to malabsorption of fat, greasy stools (steatorrhoea) and deficiency in fat soluble vitamins
Subcut insulin regimes may be required to treat diabetes
ERCP with stenting can be used to treat strictures and obstruction to the biliary system and pancreatic duct
Surgery may by required by specialist centres to treat..
. Severe chronic pain (draining the ducts and removing inflamed pancreatic tissue
. Obstruction of biliary system and pancreatic duct
. Pseudocyst
. Abscesses
What does the post transplantation care involve for liver transplantation?
Patients will require lifelong immunosuppression (e.g., steroids, azathioprine and tacrolimus) and careful monitoring of these drugs. They are required to follow lifestyle advice and require monitoring and treatment for complications:
Avoid alcohol and smoking
Treating opportunistic infections
Monitoring for disease recurrence (i.e. of hepatitis or primary biliary cirrhosis)
Monitoring for cancer as there is a significantly higher risk in immunosuppressed patients
Monitoring for evidence of transplant rejection:
Abnormal LFTs
Fatigue
Fever
Jaundice
What are the indications for liver transplant?
Can be split into two categories:
Acute liver failure or chronic liver failure
Can also be used in hepatocellular carcinoma
What are the types of liver failure?
Acute <26 weeks
Chronic liver failure is the onset of liver failure on a background of cirrhosis
What are the causes of liver failure?
Infection (hep A, B, E, CMV, yellow fever) Drugs (paracetamol overdose, halothane, isoniazid, MDMA, alcohol) Toxins Vascular Primary biliary cirrhosis Haemochromatosis Wilsons disease Autoimmhne hep Alpha 1 antitrypsin deficiency Non alcoholic fatty liver disease Fatty liver of pregnancy Malignancy HELLP
What are thr clinical features of liver failure?
Hepatic encephalopathy
Abnormal bleeding
Ascites
Jaundice
If the cerebral oedema is severe then raised ICP may develop, this is more common in fulminant hepatic failure and has a high mortality rate
It is important to distinguish the features of liver failure from chronic liver disease
What is the pathophysiology of hepatic encephalopathy?
In liver failure, nitrogenous waste (ammonia) accumulates in the circulayion
It can cross the blood brain barrier and once in the cerevral circulation it is detoxified by astrocytes
The excess glutamine disrupts the osmotic balance and astrocytes begin to swell, causing cerebral oedema
What are the four stages of hepatic encephalopathy?
1) altered mood and behaviour, disturbance of sleep pattern and dyspraxia
2) drowsiness, confusion, slurring of speech, personality change
3) incoherency, restlessness, asterixis
4) coma :(
What investigations would you do for liver failure?
Blood tests for FBC, UEs, CRP, LFT, albumin, clotting screen
If ascites is present you would do a peritoneal tap to look for spontaneous bacterial peritonitis
Abdo US
Doppler US for vudd chiari
What are the complications of liver failure?
Cerebral oedema +/- raised ICP
Blreding (where there is a source, for example during th3 ibtroduction of intracranial pressure monitors)
Hypoglycaemia
Multi organ failure
When should you do a referral for endoscopy
Urgent - all pts who have got dysphagia All patients with upper abdo mass All patients aged > or equal to 55 years who have weight loss and any of the following.., - upper abdominal pain - reflux - dyspepsia
Non urgent…
Patients with haematemesis
Pts aged > or equal to 55 years who have
- treatment resistant dyspepsia or
- upper abdo pain with
low Hb levels or raised platelet count with the following- Nausea, vomiting, weight loss, reflux, dyspepsia, upper abdo pain
How do you manage pts with dyspepsia who do not meet the referral criteria for endoscopy?
Review meds for possible causes of dyspepsia
Lifestyle advice
Trial of full dose PPI for one month or test and treat approach for H pylori
How do you test for H pylori?
Carbon 13 urea breath test or stool antigen test
What is an extradural haematoma?
Bleeding into the space between the dura mayer and the skull
It often results from accelaration- deceleration trauma or blow to the side of the head
Majority occur in the temporal region where skull fractures cause a rupture of the middle meningea, artery.
What are the features of an extradural haematoma?
Raised ICP
Some pts may exhibit a lucid interval
What is a subdural haemorrhage?
This is bleeding into the outermost meningeal layer
Most commonly occur around the frontal and parietal lobes, may be either acute or chronic
Risk factors= old age and alcoholism
Slower onset of symptoms than extradural haematoma
When do subarachnoid haemorrhage occur?
Usually spontaneously in the context of a ruptured cerebral aneurysm but may be seen in in association with other injuries when a patient has sustained a traumatic brain injury.
What is the first line investigation in acute mesenteric ischaemia?
Raised lactate
What are the 3 main conditions which involve ischaemia to the lower GI tract?
Acute mesenteric ischaemia
Chronic mesenteric ischaemia
Ischaemic colitis
What are common features in bowel ischaemia?
Increasing age
Atrial fibrillation- particularly for mesenteric ischaemia
Causes of emboli- endocarditis, malignancy
CVD risk factors: smoking, hypertension, diabetes
Cocaine- ischaemic colitis is sometimes seen in young pts following cocaine use
What are the features of bowel ischaemia?
Abdominal pain (in acute mesenteric ischaemia this is often of sudden onset, severe and out of keeping with the physical exam findings)
Rectal bleeding
Diarrhoea
Fever
Bloods showing elevated WCC associated with lactic acidosis
What is the investigation of choice for bowel ischaemia?
CT
What does acute mesenteric ischaemia usually present like, what is it usually caused by and what is the management?
Typically is caused by an embolism which results in occlusion of an artery which supplies the small bowel ie: superior mesenteric artery
The abdominal pain is typically severe, of sudden onset and out of keeping with physical exam findings
Urgent surgery is usually required
Poor prognosis if surgery delayed
What is ischaemiac colitis?
What Ix can be done?
What management?
Acute but transient compromise in the blood flow to the large bowel
This may lead to inflammation, ulceration and haemorrhage
Thumb printing may be seen on abdominal x ray due to mucosal oedema/haemorrhage
Management= usually supportive
Surgery may be required in a minority of cases if conservative measures fail
How can you check NG tube is in the right place?
Aspirate the gastric contents and check for pH <5.5
What is SBP?
Spontaneous bacterial peritonitis (SBP) is a form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis.
What are the features of SBP?
Ascites
Abdominal pain
Fever
What is the diagnosis of SBP?
paracentesis: neutrophil count > 250 cells/ul
the most common organism found on ascitic fluid culture is E. coli
What is the management of SBP?
intravenous cefotaxime is usually given
Antibiotic prophylaxis should be given to patients with ascites if:
patients who have had an episode of SBP
patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome
NICE recommend: ‘Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less until the ascites has resolved’
What is TURP syndrome?
TURP syndrome is a rare and life-threatening complication of transurethral resection of the prostate surgery.
It is caused by irrigation with large volumes of glycine, which is hypo-osmolar and is systemically absorbed when prostatic venous sinuses are opened up during prostate resection. This results in hyponatremia, and when glycine is broken down by the liver into ammonia, hyper-ammonia and visual disturbances.
What are the complications of pancreatitis?
Pseudocyst Abscess Necrosis ARDS Haemorrhage
What is the common cause for aucte cholangitis?
E.coli
How do you manage acute cholangitis?
Management
intravenous antibiotics
endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction
What are the types of shock?
Anaphylaxis Cardiogenic Neurogenic Haemorrhagic Septic
How does neurogenic shock occur?
Basically there is disruption in the ANS
and you get peripheral vasodilation
what is cardiogenic shock?
In medical patients the main cause is ischaemic heart disease. In the traumatic setting, direct myocardial trauma or contusion is more likely. Evidence of ECG changes and overlying sternal fractures or contusions should raise the suspicion of injury. Treatment is largely supportive and transthoracic echocardiography should be used to determine evidence of pericardial fluid or direct myocardial injury. The measurement of troponin levels in trauma patients may be undertaken but they are less useful in delineating the extent of myocardial trauma than following MI.
When cardiac injury is of a blunt nature and is associated with cardiogenic shock the right side of the heart is the most likely site of injury with chamber and or valve rupture. These patients require surgery to repair these defects and will require cardiopulmonary bypass to achieve this. Some may require intra-aortic balloon pump as a bridge to surgery.
What is the treatment of fissures?
If they have been present for <1 weeks:
- Soften stool
- Lubricants
- Topical anaesthetics
- Analgesia
Chronic anal fissure…
Topical GTN
if this doesn’t help after 8 weeks then botulinum injection or sphincterotomy
What is reynolds pentad?
This is a sign of more severe acute cholangitis
and involves charcots triad + hypotension + confusion
What is the first line investigation in SBO?
AXR
CT is more definitive and is more sensitive
What can reduce the formation of
A) calcium stones
B) uric acid stones
A) Thiazide diuretics
B) Allopurinol
What is wound dehiscence?
When all the layers of the abdomen fail to close and viscera protrude externally
It can be superficial- which is just the skin itself or complete- all layers of the abdomen
Factors that increase the risk; Jaundice Steroid use Malnutrition Vitamin deficiencies Major wound contamination Poor surgical technique
How do you treat wound dehiscence?
Coverage of the wound with saline impregnated gauze IV broad spec abx Analgesia IV fluids Arrangements made for return to theatre
What is a common complication of Subarachnoid haemorrhage?
SIADH- causes fluid retention causing hyponatraemia
What drugs cause acute pancreatitis?
Sodium valproate
Bendroflumethiazide
Furosemide
Steroids
What are the SES of sodium valproate?
V- vomiting A- Alopecia L- Liver toxicity P- Pancreatitis R- Retention of fats O- Oedema A- Appetite increases T- teratogenic E- Enzyme inducers
What does gastric volvulus present with?
Triad of vomiting, pain and failed attempts to pass an NG tube.
When should you conisder fixing undescended testes?
6-8 months
What is the treatment of chronic pancreatitis?
Analgesia
Pancreatic enzyme supplements
Antioxidants- benefit in early disease
Features of pancreatic cancer?
Pain
Steatorrhoea- 5 and 20 years after
Diabetes 20 years after
What is the IX of choice for chronic pancreatitis?
CT is the most sensitive
What is acute urinary retention?
This is when a person suddenly (hours or less) becomes unable to pass urine voluntarily
What are the causes of acute urinary retention?
Men- BPH, urethral strictures, calculi, cystocele, constipation, masses
Medications- anticholinergics, TCAS, antihistamine, opioids, benzos
UTI
post op
Post partum
How does acute urinary retention present?
Acute= Inability to pass urine lower abdominal discomfort Considerable pain or distress Acute confusional state (delirium) Lower abdominal tenderness Palpable distended urinary bladder
All men and women should have a rectal and neurological examination
Women should have a pelvic exam
What are the investigations for acute urinary retention?
Sample for microscopy and culture
Serum urine and creatinine
A FBC and CRP
PSA
How do you diagnose acute urinary retention?
What is the management?
A bladder ultrasound should be performed
A volume of >300ml confirms the diagnosis, but if the hx and examination are consistent with acutre urinary retention but the bladder scan doesn’t show this, then the patient can still be in acute urinary retention
Urinary catheterisation can be performed in pts with suspected acute urinary retention
What is a complication of acute urinary retention?
Post obstructive diuresis
What is a thrombosed haemorrhoid?
A haemorrhoid that has become swollen due to a small blood clot within the haemorrhoid
Typically presents with significant pain and a tender lump
purplish, oedematous, tender subcutaneous perianal mass
if pt presents within 72 hours then referral should be considered for excision, otherwise they can be managed with analgesia, stool softeners, ice packs
How does malrotation present?
It most common in babies <30 days
Bilious vomiting
The abdomen is soft and non tender initially but if untreated it leads to strangulation of the gut- distended and firm abdomen, lack of stool
What does necrotising enterocolitis present with?
Abdo pain, swelling, diarrhoea, bloody stool green/yellow vomit lethargy refusal to eat lack of weight gain More common in premature babies
How does pyloric stenosis present?
Vomiting is non bilious and typically projectile
4-8 weeks
Weight loss and dehydration are very common at presentation
Visible peristalsis
Palpable olive sized pyloric mass
What is Suxamethonium apnoea?
Also called pseudocholinesterase deficiency
It is a rare abnormality in the production of plasma cholinesterases
It leads to an increased duration of muscle relaxants- suxamethonium
Respiratory arrest in inevitable
What is xanthochromia?
This is the yellowish appearance of CSF occuring as a result of RBC breakdown and bilirubin release
It suggests a bleed into the red
What is the cause of SAH?
AV malformation
arterial dissection
Intracranial aneurysm
pituitary apoplexy
What are the presentations of SAH?
Headache- sudden onset, severe, occipital Nausea and vomiting Meningism Coma Seizures sudden death
IX of SAH?
CT intracranial angiogram
What is the treatment of SAH?
Coil by interventional neuroradiologists
Until the aneurysm is treated, the pt should be kept on strict bed rest, well controlled blood pressure and should avoid straining in order to prevent a re-bleed of the aneurysm
Vasospasm is prevented using a 21 day course of nimodipine
Hydrocephalus is temporarily treated with an external ventricular drain or, if required
What are the complications of aneurysm SAH?
Re bleeding Vasospasm Hyponatraemia (SIADH) Seizures Hydrocephalus Death
What are the rules for when you should do a PSA test?
6 weeks after prostate biopsy
4 weeks after proven UTI
1 week after DRE
48 Hrs after ejaculation or vigorous exercise
What is the psoas sign?
When the right thigh is passively extended with the pt lying on their sides with their knees extended
What is the treatment of an anastanomic leak?
Surgical emergency and patients must be taken back to theatre ASAP
What should you do if you cant get a peripheral cannula in to increase BP?
contact someone to put IO in as PICC lines and Central lines take to long
What are the risk factors for testicular cancer?
Undescended testes Positive family history Infertility Mumps orchitis Klinefelter's syndrome
with metastatic prostate cancer, it is often treated with hormonal therapy ie: goserelin, what should be co-prescribed with this?
Cyprotene acetate (anti androgen) 3 days before
What can PPIs cause?
Hyponatraemia Hypomagnasium Osteoporosis --> increased risk of fractures Microscopic colitis Increased C difficile infections
What is Barrett’s oesophagus and what are the risk factors/management?
It is the METAPLASIA of lower oesophageal mucosa with the usual squamous epithelium being replaced by columnar epithelium
GORD/MALE/ SMOKING/CENTRAL OBESITY
Endoscopic surveillance with biopsy
High dose PPI
For patients with metaplasia, endoscopy is needed every 3-5 years
If dysplasia of any grade is identified;
- Endoscopic Mucosal resection
- Radiofrequency ablation
How long do patients with coeliac need to eat gluten before their diagnosis?
6 WEEKS
What genetic mutations are associated with
a) HNPCC (LYNCH)
b) FAP
a) MSH2, MLH1
b) APC
What is diagnostic of malnutrition?
Unintentional weight loss >10% within the last 3-6 months
What is the significance in urea in the context of anaemia?
High urea levels indicate upper GI bleed over lower GI bleed
What rate should maintenance fluids be prescribed at if pt can’t drink?
30ml/kg/hour
You may want to initially give 500ml and then reassess the patients ability to drink
What medication can cause a haemolytic anaemia (indicated by presence of heinz bodies)?
Sulfasalazine which is used for IBD
Bile acid malabsorption after cholecystectomy or during crohns, how can it be treated?
Cholestyramine
What is primary sclerosing cholangitis and what antibody is it associated with?
Biliary disease of unkown aetiology characterised by inflammation and fibrosis of the extra and intrahepatic ducts
pANCA
complications include cholangiocarcinoma and increased risk of colorectal cancer
What antibodies are associated with autoimmune hepatitis?
ANA
Anti smooth muscle antibodies
raised IgG levels
