GI/general Surgery Flashcards

Question

What is coeliac disease?

Answer 1

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

Answer 2

Anti tissue transglutaminase and anti endomysial

Answer 3

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

Answer 4

Dermatitis herpetiformis (itchy blistering skin rash typically on the abdomen)

Answer 5

Coeliac disease as the conditions are often linked

Answer 6

HLA-DQ2 gene (90%) | HLA- DQ8 gene

Answer 7

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

Answer 8

``` T1DM Thyroid disease Autoimmune hepatitis Primary biliary cirrhosis Primary sclerosing cholangitis ```

Answer 9

``` Vitamin deficiency Anaemia Osteoporosis Ulcerative jejunitis Non hodgkin lymphoma Small bowel adenocarcinoma (rare) ```

Answer 10

``` Jaudice Hepatomegaly Spider naevi Palmar erythema Gynaecomastia Bruising Asterixis Ascites Caput medusae(engorged superficial epigastrix veins) ```

Answer 11

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

Answer 12

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)

Answer 13

6-12 hours- tremor, sweating, headache, craving, anxiety 12-24- hallucination 24-48- seizures 24-72 hrs- delirium tremens

Answer 14

A medical emergency associated with alcohol withdrawal, has a mortality of 35% if left untreated

Answer 15

``` Acute confusion Severe agitation Delusions and hallucinations Tremor Tahycardia Hypertension Hyperthermia Ataxia Arrythmia ```

Answer 16

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)

Answer 17

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.

Answer 18

Alcoholic liver disease Non alcoholic fatty liver disease Hep B Hep C

Answer 19

``` Jaundice Hepatomegaly Splenomegaly Palmar erythema Gynaecomastia Bruising Ascites Caput medusae Asterixis ```

Answer 20

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)

Answer 21

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

Answer 22

End colostomy Loop colostomy Double barrel colostomy

Answer 23

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)

Answer 24

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

Answer 25

After bladder cancer, it uses ileum to attach to ureters and skin

Answer 26

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

Answer 27

Low fibre for first two months

Answer 28

Removal of the rectosignmoid colon with closure of the anorectal stump and formation of a colostomy

Answer 29

Encourages the pt to mobilise, ventilate their lungs fully and have adequate oral intake

Answer 30

In asthma, renal impairment, heart disease and stomach ulcers.

Answer 31

Naloxone infusion

Answer 32

``` Female History of motion sickness or previous PONV Non smoker Use of post op opiates Younger age Use of volatile anaesthetics ```

Answer 33

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

Answer 34

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.

Answer 35

A tube from the surface of the abdomen to the stomach

Answer 36

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.

Answer 37

``` 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 ```

Answer 38

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

Answer 39

``` 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 ```

Answer 40

``` 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) ```

Answer 41

Third spacing refers to fluid shifting into the non functional third space (interstitium), often this refers to the development of oedema

Answer 42

Inflammation of the appendix

Answer 43

A small, thin tube arising from the caecum.

Answer 44

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.

Answer 45

Mostly a clinical diagnosis Can use USS (kids, women), CT Diagnostic laparoscopy if clinical presentation indicates appendicitis but investigations are negative

Answer 46

Describes inflamed abdominal lymph nodes, it presents with abdominal pain, usually in younger children. Often associated with tonsilitis or URTI. No spec treatment needed

Answer 47

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.

Answer 48

``` Bleeding Infection VTE Pain Scars Damage to bowel, bladder or other organs Anaesthetic risks ```

Answer 49

Adhesions (small bowel), hernias (small bowel), malignancy (large bowel) Volvulus (large bowel) Diverticular disease Strictures ie: secondary to crohns Intussusception

Answer 50

Hernias, change in bowel habit, weight loss, PR bleeding (bowel cancer), previous surgery

Answer 51

Abdo or pelvic surgery Peritonitis Abdominal or pelvic infections Endometriosis

Answer 52

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 ```

Answer 53

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

Answer 54

Hypovolemic shock Bowel ischaemia Bowel perforation Sepsis

Answer 55

Electrolyte imbalances Metabolic alkalosis due to stomach acid (VBG) Bowel ischaemia (raised lactate- either on VBG or lab sample)

Answer 56

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

Answer 57

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.

Answer 58

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.

Answer 59

Injury to the bowel Handling of the bowel during surgery Inflammation or infection in, or nearby the bowel Electrolyte imbalance (hypokalaemia, hyponatraemia)

Answer 60

Same as BO

Answer 61

``` 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 ```

Answer 62

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.

Answer 63

Sigmoid volvulus | Caecal volvulus

Answer 64

``` Neuropsychiatric disorders- parkinsons Nursing home residents Chronic constipation High fibre diet Pregnancy Adhesions ```

Answer 65

Signs and symptoms are same ad bowel obstruction; Vomiting (particularly green bilious vomiting) Abdominal distention Diffuse abdominal pain Absolute constipation and lack of flatulence

Answer 66

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.

Answer 67

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

Answer 68

Incarcentation Strangulation Obstruction

Answer 69

Conservative- pts with a wide neck, not good candidates for surgery Mesh repair (tension free pair) Tension repair

Answer 70

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.

Answer 71

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.

Answer 72

Laparoscopic fundoplication (if high risk of complications or symptoms are resistant to medical treatment)

Answer 73

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) ```

Answer 74

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

Answer 75

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

Answer 76

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

Answer 77

Require admission to hospital - NBM/ clear fluids only - IV abx - IV fluids - analgesia - CT scan - urgent surgery may be required for complications

Answer 78

``` Perforation Peritonitis Peridiverticular abscess Large haemorrhage requiring blood transfusions Fistula Ileus/obstruction ```

Answer 79

Stomach, part of the duodenum, biliary system, liver, pancreas and spleen Coeliac artery

Answer 80

From the distal part of the duodenum to the first half of the transverse colon Supplied by the superior mesenteric artery

Answer 81

This is from the second half of the transverse colon to the rectum, this is supplied by the inferior mesenteric artery

Answer 82

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.

Answer 83

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

Answer 84

``` Same as any other cardiovascular disease… Increased age Family history Smoking Diabetes Hypertension Raised cholesterol ```

Answer 85

CT angiography

Answer 86

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) ```

Answer 87

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.

Answer 88

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.

Answer 89

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

Answer 90

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

Answer 91

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.

Answer 92

``` 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 ```

Answer 93

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.

Answer 94

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.

Answer 95

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

Answer 96

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

Answer 97

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.

Answer 98

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

Answer 99

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.

Answer 100

TNM classification

Answer 101

Surgical resection Chemotherapy Radiptherapy Palliative care

Answer 102

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)

Answer 103

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

Answer 104

``` Pancreatitis Acute cholecystitis Acute cholangitis Bouverets Gallstone ileus ```

Answer 105

Fat, fair, forty, female

Answer 106

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

Answer 107

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.

Answer 108

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

Answer 109

Ultrasound scan

Answer 110

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.

Answer 111

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

Answer 112

Excessive bleeding Cholangitis Pancreatitis

Answer 113

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.

Answer 114

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

Answer 115

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

Answer 116

Inflammation of the gallbladder, which is caused by blockage of the cystic duct preventing the gallbladder from draining.

Answer 117

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

Answer 118

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

Answer 119

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).

Answer 120

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.

Answer 121

Sepsis Gallbladder empyema Gangrenous gallbladder Perforation

Answer 122

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)

Answer 123

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.

Answer 124

Obstruction in the bile ducts stopping bile flow (i.e. gallstones in the common bile duct) Infection introduced during an ERCP procedure

Answer 125

Eschericia coli Klebsiella species Enterococcus species

Answer 126

Acute cholangitis presents with charcots triad, this is: Right upper quadrant pain Fever Jaundice (raised bilirubin)

Answer 127

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 ```

Answer 128

Abdominal ultrasound scan CT scan Magnetic resonance cholangio-pancreatography (MRCP) Endoscopic ultrasound (Least to most sensitive)

Answer 129

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

Answer 130

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

Answer 131

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.

Answer 132

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.

Answer 133

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

Answer 134

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

Answer 135

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.

Answer 136

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

Answer 137

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.

Answer 138

Pancreatic cancer

Answer 139

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 ```

Answer 140

Courvoisier’s law states that a palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic cancer.

Answer 141

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.

Answer 142

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.

Answer 143

Surgery ?whipples procedure- pancreaticduodenectomy only for cases that are confined to head of pancreas Palliative care

Answer 144

``` 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) ```

Answer 145

Epigastric pain, radiating to back Nausea Vomiting Systemically unwell (low grade fever and tachy)

Answer 146

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)

Answer 147

GLASGOW SCORE 0 or 1= mild pancreatitis 2= moderate pancreatitis 3 or more= severe pancreatitis

Answer 148

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) ```

Answer 149

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.

Answer 150

``` 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 ```

Answer 151

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

Answer 152

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

Answer 153

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

Answer 154

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

Answer 155

Can be split into two categories: Acute liver failure or chronic liver failure Can also be used in hepatocellular carcinoma

Answer 156

Acute <26 weeks | Chronic liver failure is the onset of liver failure on a background of cirrhosis

Answer 157

``` 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 ```

Answer 158

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

Answer 159

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

Answer 160

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 :(

Answer 161

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

Answer 162

Cerebral oedema +/- raised ICP Blreding (where there is a source, for example during th3 ibtroduction of intracranial pressure monitors) Hypoglycaemia Multi organ failure

Answer 163

``` 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

Answer 164

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

Answer 165

Carbon 13 urea breath test or stool antigen test

Answer 166

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.

Answer 167

Raised ICP | Some pts may exhibit a lucid interval

Answer 168

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

Answer 169

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.

Answer 170

Raised lactate

Answer 171

Acute mesenteric ischaemia Chronic mesenteric ischaemia Ischaemic colitis

Answer 172

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

Answer 173

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

Answer 174

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

Answer 175

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

Answer 176

Aspirate the gastric contents and check for pH <5.5

Answer 177

Spontaneous bacterial peritonitis (SBP) is a form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis.

Answer 178

Ascites Abdominal pain Fever

Answer 179

paracentesis: neutrophil count > 250 cells/ul | the most common organism found on ascitic fluid culture is E. coli

Answer 180

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'

Answer 181

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.

Answer 182

``` Pseudocyst Abscess Necrosis ARDS Haemorrhage ```

Answer 183

Management intravenous antibiotics endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction

Answer 184

``` Anaphylaxis Cardiogenic Neurogenic Haemorrhagic Septic ```

Answer 185

Basically there is disruption in the ANS | and you get peripheral vasodilation

Answer 186

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.

Answer 187

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

Answer 188

This is a sign of more severe acute cholangitis | and involves charcots triad + hypotension + confusion

Answer 189

AXR | CT is more definitive and is more sensitive

Answer 190

A) Thiazide diuretics | B) Allopurinol

Answer 191

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 ```

Answer 192

``` Coverage of the wound with saline impregnated gauze IV broad spec abx Analgesia IV fluids Arrangements made for return to theatre ```

Answer 193

SIADH- causes fluid retention causing hyponatraemia

Answer 194

Sodium valproate Bendroflumethiazide Furosemide Steroids

Answer 195

``` V- vomiting A- Alopecia L- Liver toxicity P- Pancreatitis R- Retention of fats O- Oedema A- Appetite increases T- teratogenic E- Enzyme inducers ```

Answer 196

Triad of vomiting, pain and failed attempts to pass an NG tube.

Answer 197

6-8 months

Answer 198

Analgesia Pancreatic enzyme supplements Antioxidants- benefit in early disease

Answer 199

Pain Steatorrhoea- 5 and 20 years after Diabetes 20 years after

Answer 200

CT is the most sensitive

Answer 201

This is when a person suddenly (hours or less) becomes unable to pass urine voluntarily

Answer 202

Men- BPH, urethral strictures, calculi, cystocele, constipation, masses Medications- anticholinergics, TCAS, antihistamine, opioids, benzos UTI post op Post partum

Answer 203

``` 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

Answer 204

Sample for microscopy and culture Serum urine and creatinine A FBC and CRP PSA

Answer 205

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

Answer 206

Post obstructive diuresis

Answer 207

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

Answer 208

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

Answer 209

``` Abdo pain, swelling, diarrhoea, bloody stool green/yellow vomit lethargy refusal to eat lack of weight gain More common in premature babies ```

Answer 210

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

Answer 211

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

Answer 212

This is the yellowish appearance of CSF occuring as a result of RBC breakdown and bilirubin release It suggests a bleed into the red

Answer 213

AV malformation arterial dissection Intracranial aneurysm pituitary apoplexy

Answer 214

``` Headache- sudden onset, severe, occipital Nausea and vomiting Meningism Coma Seizures sudden death ```

Answer 215

CT intracranial angiogram

Answer 216

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

Answer 217

``` Re bleeding Vasospasm Hyponatraemia (SIADH) Seizures Hydrocephalus Death ```

Answer 218

6 weeks after prostate biopsy 4 weeks after proven UTI 1 week after DRE 48 Hrs after ejaculation or vigorous exercise

Answer 219

When the right thigh is passively extended with the pt lying on their sides with their knees extended

Answer 220

Surgical emergency and patients must be taken back to theatre ASAP

Answer 221

contact someone to put IO in as PICC lines and Central lines take to long

Answer 222

``` Undescended testes Positive family history Infertility Mumps orchitis Klinefelter's syndrome ```

Answer 223

Cyprotene acetate (anti androgen) 3 days before

Answer 224

``` Hyponatraemia Hypomagnasium Osteoporosis --> increased risk of fractures Microscopic colitis Increased C difficile infections ```

Answer 225

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

Answer 226

a) MSH2, MLH1 | b) APC

Answer 227

Unintentional weight loss >10% within the last 3-6 months

Answer 228

High urea levels indicate upper GI bleed over lower GI bleed

Answer 229

30ml/kg/hour | You may want to initially give 500ml and then reassess the patients ability to drink

Answer 230

Sulfasalazine which is used for IBD

Answer 231

Cholestyramine

Answer 232

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

Answer 233

ANA Anti smooth muscle antibodies raised IgG levels