GI/hepatobiliary Flashcards
Pancreatitis
Inflammation of the pancreatitis
- Acute: rapid onset, function returns after
- Chronic - longer-term inflammation and symptoms, progressive, permenant deterioration in function
Causes of pancreatitis
Key causes:
- Gallstones
- Alcohol
- Post-ERCP (endoscopic retrograde cholangiopancreatography)
I GET SMASHED mnemonic: Idiopathic, Gallstones, Ethanol, Trauma, Steriods, Mumps, Autoimmune, Scorpion sting, Hyperlipidaemia, ERCP, Drugs (furosemide, thiazide diuretics and azathioprine)
Presentation of pancreatitis
Acute: clinical dx with presentation + amylase levels
- Severe epigastric pain
- Radiating through to the back
- Associated vomiting
- Abdominal tenderness
- Systemically unwell (e.g., low-grade fever and tachycardia)
Chronic = similar symptoms but longer period of onset
Investigations for acute pancreatitis
Ix for acute abdomen: FBC (WCC), U+Es (urea), LFTs (transaminases and albumin), Calcium, ABG (PaO2 and BM)
- Amylase = raised x3
- Lipase = more senesitive + specific
- CRP
- USS if gallstones suspected
- CT abdo if complications suspected+
+ Necrosis, abscesses, fluid collection
Glasgow Score for severity of pancreatitis
PANCREAS mnemonic:
- P – Pa02 < 8 KPa
- A – Age > 55
- N – Neutrophils (WBC > 15)
- C – Calcium < 2
- R – uRea >16
- E – Enzymes (LDH > 600 or AST/ALT >200)
- A – Albumin < 32
- S – Sugar (Glucose >10)
0/1 = mild
2 = moderate
3 or more = severe
Management of acute pancreatitis
- Admit for supportive mx, moderate/severe = HDU/ICU
- ABCDE + aggressive fluid resus
- IV fluids
- Analgesia
- Oral/parenteral nutrition
- Careful monitoring
- Gallstone tx (ERCP/cholecystectomy)
- Abx if infection
- Complications tx
Should improve in a week
Chronic pancreatitis
Alcohol is common cause, fibrosis adn reduced function
Key complications:
- Chronic epigastric pain
- Loss of exocrine (pancreatic enzymes) and endocrine (insulin) function
- Damage + strictures = obstruction of pancreatic juice and bile
- Pseudocysts and abscesses
Management of chronic pancreatitis
- Stop alcohol and smoking
- Analgesia
- Creon (replacement pancreatic enzymes)
- SC insulin reigme if diabetes
- ERCP with stenting if strictures and obstruction
Bowel cancer (colorectal)
4th most common cancer in UK (after breast, prostate and lung)
Risk factors
- FHx
- Familial adenomatous polyposis (FAP)
- Hereditary nonpolyposis colorectal cancer (HNPCC) i.e. Lynch syndrome
- IBD
- Increased age
- Diet high in processed meat and low in fibre
- Obesity and sedentary lifestyle
- Smoking
- Alcohol
Presentation of bowel cancer
Red flags:
- Change in bowel habit
- Unexplained weight loss
- Rectal bleeding
- Unexplained abdo pain
- Iron-deficency anaemia (IDA)
- Abdo/rectal mass
2WW criteria
- > 40 with abdo pain + unexplained weight loss
- > 50 with rectal bleeding
- > 60 with change in bowel habit or IDA
Unexplained IDA is indication for 2WW referral for colonscopy/gastroscopy for GI malignancy
Screening and investigation for bowel cancer
- Faecal immunochemical test (FIT)- looks for human haemoglobin in stool
- Screening for 60 - 74 y/o every 2 years
- Colonscopy is gold standard Ix, suspicious lesions are biopsied
TNM classification of bowel cancer
Tumour, Node, Metastasis
Tumour:
- Tx - unable to assess size
- T1 - submucosa
- T2: spread to muscularis propria (muscle)
- T3: Subserosa and serosa (outer later)
- T4: Serosa (4a), other tissues/organs (4b)
NX - unable to assess nodes
N0 - no nodal spread
N1: 1 - 3 nodes
N2: > 3 nodes
M0 - no metastasis
M1 - metastasis
Management of bowel cancer
- MDT: surgeons, oncologists, radiologists, histopathologists, specialist nurses
- Surgical resection
- Chemo
- Radioherapy
- Palliative care
Follow-up for a period of time e.g. 3 years:
- Serum carcinoembryonic antigen (CEA)
- CT thorax, abdomen and pelvis
Alcoholic-related liver disease
Stages
1. Alcoholic fatty liver (hepatitic steatosis) - buildup of fat, reversible with abstinence
2. Alcoholic hepatitis - long-term alcohol use = liver cell inflammation, mild is reversible with abstinence
3. Cirrhosis - scar tissue replaces functional liver tissue, irreversible
Complications of alcohol
- Alcohol-related liver disease
- Cirrhosis and its complications (e.g., hepatocellular carcinoma)
- Alcohol dependence and withdrawal
- ↑ CVD risk
- Wernicke-Korsakoff syndrome (WKS)
- Pancreatitis
- Alcoholic cardiomyopathy
- Alcoholic myopathy, with proximal muscle wasting and weakness
- ↑ cancer risk, particularly breast, mouth and throat cancer
Investigations for alcohol-related liver disease
- ↑MCV
- ↑ALT and AST
- AST:ALT ratio above 1.5
- ↑ GGT
- ↑ ALP late stage
- ↑ bilirubin in cirrhosis
- ↑ prothrombin time
- ↓albumin
- Liver USS = fatty changes “increased echogenicity”, cirrhotic changes
- Fibroscan for fibrosis degree
- Endoscopy to assess and treat oesophageal varice if portal HTN
- Diagnostic = liver bopsy
Management of alcohol-related liver disease
- Stop drinking
- Detox reigme
- Referal to drugs and alcohol services
- Psychological interventions (motivational interviewing, CBT)
- Thiamine and high-protein diet
- Corticosteroids short-term for inflammation
- Tx complications of cirrhosis - portal HTN, vrices, ascites and hepatocellular carcinoma
- Liver transplant (at least 6m abstinence)
Anal fissure
Longitudinal/elliptical tears of the squamous lining of the distal anal canal
RFs: constipation, IBD, STI e.g. HIV/syphilis
Clinical features of anal fissures
- Painful, bright red, rectal bleeding
- 90% on posterior midline
- If other locations, consider alternative dx e.g. Crohn’s
Management of anal fissure
Acute (1w)
- Soften stool - fibre,fluid, bulk-forming laxatives (e.g. ispaghula husk) 1st line
- Lubricants e.g. petroleum jelly
- Topical anaesthetics
- Analgesia
Chronic
- As above
- 1st line - topical glyceryl trinitrate
Appendicitis
Inflammation of appendix, a long thin tube arising from caecum, pathogens can get trapped > infection + inflammation > gangrene and rupture
Peak 10 to 20 years old
Clinical features of appendicitis
CLassic:
- Central abdo pain than moves and localises to RIF
- Tenderness on palpation at McBurney’s point
- Anorexia
- N+V
- Fever
- Rovsing’s sign (palpation of LIF = pain in RIF)
- Guarding on abdo palpation
- Rebound tenderness in RIF (↑pain on releasing deep palpation) + Percussion tenderness = peritonitis = rupture
Diagnosis of appendicitis
- Clinical presentation and raised inflammatory markers
- Diagnostic = CT
- Key ddx: ectopic pregnancy (hCG), ovarian cysts (pelvic and iliac fossa pain if rupture or torsion)
If woman of child-bearing age, assume pregnant until proven otherwise with test
Management of appendicitis
- Emergency admission under sugical team
- Laparoscopic/open appendicetomy
- Complication: bleeding, infection, damage to bowel, bladder, other organs, removal of normal appendix, VTE
