GI & Surgery Flashcards
Achalasia
Degenerative loss of nerves in Auerbach’s plexus leads to failure of relaxation of LOS
= dysphagia of liquids and solids, regurg, heartburn, cough
Inv - oes manometry (inc LOS tone), barium swallow (fluid level, bird beak), CXR (wide mediastinum)
-> balloon dilatation, Heller cardiomyotomy, botox
Pharyngeal Pouch
Posteromedial herniation between thryopharyngeus and cricopharyngeus muscles (killian’s).
RF - old, 5M:F
= dysphagia, bad breath, gurgling on swallowing, cough, regurg, aspiration
Inv - barium swallow + dynamic video fluoroscopy
-> surgery
Oesophageal Cancer
Squamous (upper 2/3)
- Linked with PV, smoking, alcohol, achalasia, nitrosamines in diet.
Adeno (lower 1/3, most common)
- Linked with GORD, Barrett’s, smoking, obesity
= dysphagia, anorexia, weight loss, vomiting, odynophagia, hoarse, melaena, cough
Inv - upper GI scope + biopsy, endo US to locally stage, CT TAP
-> surgical resection (anastomotic leak and mediastinitis risk), adj chemo
Plummer-Vinson syndrome
Triad of iron deficient anaemia, dysphagia (oes webs) and glossitis
-> iron supp, web dilation
Other Causes of Dysphagia
Oesophagitis - heartburn, pain, no weight loss, systemically well
Candidiasis - Hx HIV or steroid inhaler use
SS - other CREST features (v LOS pressure)
Myasthenia Gravis - extraocular muscle weakness and ptosis
Globus - painless, swallowing helps, Hx anxiety
GORD
Reflux of stomach contents into the oesophagus.
= heart burn, regurg, nocturnal cough, epigastric pain, hoarseness
Referral for upper endoscopy if;
- >55, weight loss, dysphagia, symptoms >4 weeks or no response to treatment
Consider 24hr oes pH monitoring if negative
Comp - oesophagitis, ulcers, anaemia, strictures, Barrett’s, oes cancer
Management of GORD
Lifestyle advice - reduce tea, coffee, weight, smoking, stand after meals, smaller meals
Endoscope +ve -> full dose PPI for 1-2 months
- Response: low dose as required
- No response: double for 1month
Endoscope -ve -> full dose PPI for 1 month
- Response: low dose as required
- No response: prokinetic or H2RA 1 month
Mesenteric Ischemia
RF - age, AF, cancer, CVD RF and cocaine (ischemic colitis).
Acute
= severe sudden abdo pain»_space; exam, PR blood
Inv - ^WCC, lactic acidosis
-> immediate laparotomy
Chronic
= intestinal angina, colicky
Ischemic colitis
= acute but transient loss (^splenic flexure)
Inv - AXR (thumbprinting), CT (segmental thickening of large bowel wall, pericolic fat stranding)
-> conservative
Biliary Colic
^cholesterol, biliary stasis and v bile salts = stone formation = obstruction and colic
RF - fat, female, fertile, 40, DM, Crohn’s, rapid weight loss, fibrates, COCP
= colicky RUQ pain, radiates to R shoulder, worse after fatty foods, n+v, NO FEVER, NORMAL BLOODS
Inv - US
-> elective lap cholecystectomy
Acute Cholecystitis
Inflammation of the gallbladder
90% due to calculi, 10% severely ill/ IC patients 2nd to cryptosporidium or CMV
= RUQ pain, to right shoulder + FEVER and systemic upset, murphys +ve
Inv - normal LFT unless Mirizzi syndrome (in distal cystic duct compress CBD), US, HIDA if unclear
-> IV Abx, lap chole within 1 week
Gallstone complications
Mucocele
Abscess/ empyema (swinging fever, US +/- CT)
Gallstone ileus (remove stone, don’t touch GB)
Ascending Cholangitis
Bacterial infection of the biliary tree (^^E.coli)
RF - gallstones, ERCP
= Charcot’s fever (rigors), RUQ pain and jaundice,
Reynolds pentad is hypotension and confusion
Inv - ^LFT, ^inflam, blood cultures, US (dilated BD/ stones), MRCP (CT overnight)
-> IV fluids, IV Abx, ERCP to relieve obstruction
Drugs causing cholestasis
COCP
Fluclox, co-amoxiclav and erythromycin
Testosterone, anabolic steroids
Sulphonylurea
Fibrates
Chlorpromazine
Drugs causing hepatocellular picture
Paracetamol
Phenytoin
Sodium valproate
Statins
Alcohol
Amiodarone
Methyldopa
MAOI
TB drugs
Nitrofurantoin
Chronic Pancreatitis
80% due to alcohol excess, 20% unexplained
Other causes - CF, haemochromatosis, tumour, stones, pancreas divisum and annular pancreas
= severe abdo pain 15-30 min after meal, steatorrhea (5-25yrs), DM (20yrs)
Inv - AXR (calcification), CT best, faecal elastase to assess exocrine function
-> enzyme supplements, analgesia
Acute Pancreatitis
Autodigestion of pancreatic tissue
Causes - I GET SMASHED
= severe epigastric pain, through to back, n+v, low-grade fever, ileus, Cullen’s (periumbilcial) or Grey-Turner’s (flank), rarely retinopathy
Inv - amylase (3x upper limit), lipase (longer half life), early US for cause, CT diagnose if unsure, ABG for score
-> fluid resus, analgesia, antiemetics, no need for NBM (enteral feeding is used if moderate or severe) and no prophylactic Abx, 4hourly glucose, AC
Glasgow scoring system
Severity of Pancreatitis. Score of 3 is severe.
Pa02 - under 8
Age - over 55
Neutrophils - over 15
Calcium - under 2
Renal - urea over 16
Enzymes - LDH over 600 or AST over 200
Albumin - under 32
Sugar - over 10
Acute Pancreatitis - Causes
I GET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion
Hyperlipidaemia
ERCP
Drugs - azathioprine, mesalazine, thiazides and furosemide
Diarrhoea ABG
Anion Gap = all positive ions - negative ions Normally 10-18
Diarrhoea
Loss of bicarb and K from GI tract - hypokalemia metabolic acidosis
Hep A
RNA picornavirus, faecal-oral spread
= self-limiting, flu-like prodrome, RUQ pain, tender hepatomegaly, jaundice
Inv - ^LFTs
No inc risk of HCC
Vacc - travelling, CLD, gay M, IVDU, occupational
Hepatitis B
dsDNA hepadnavirus,
Spread via body fluids and vertical transmission
Comp - chronic Hep (ground glass hepatocytes), HCC, GN, polyarteritis nodosa and cryoglobulinaemia
-> antivirals, pre interferon-a
Hep B Serology
HBsAg - first marker, active infection if positive (acute <6m and chronic >6m)
Anti-HBs - immunity (exposure and immunized)
Anti-HBc - c for caught (previous or current)
- IgM acute
- IgG persists
Anal Fissure
Longitudinal tears of the squamous lining, acute <6wks
RF - constipation, IBD, STI (HIV, herpes, syphilis)
= painful bright red bleeding, posterior midline (? cause if not)
-> (acute) diet advice. bulk-forming laxities, lubes, analgesia, anesthetic cream
(chronic) GTN for 8 weeks, no response then refer for sphincterotomy/botox
Primary Biliary Cholangitis
AI inflam of interlobular bile ducts = cholestasis
Link - Sjogren’s, RA, SS, thyroid
= middle-age F, itching, jaundice, RUQ pain, hyperpigmentation (pressure points), xanthelasma, clubbing, organo, liver failure
Inv - AMA, ASMA, IgM, ALP, US/ MRCP
-> urodeoxycholic acid (slows progression), cholestyramine, fat-sol vitamins, transplant (BR >100)
Comp - cirrhosis, portal HTN, ascites, varices,
osteomalacia/porosis, 20 x HCC
Primary Sclerosing Cholangitis
Inflammation and fibrosis of the intra and extra hepatic bile ducts
Link - UC, HIV, Crohn’s
= cholestasis (jaundice, pruritis), RUQ and fever
Inv - ^BR, ^ALP, MRCP diagnosis, some p-ANCA+
Comp - 10% risk of cholangiocarcinoma, CRC
UC Flare
Mild - <4 shits, minimal blood, normal CRP
Moderate - 4-6, minor systemic
Severe - >6, blood, systemic upset (fever, ^HR, anaemia, v albumin)
Inducing remission:
Proctitis -> rectal ASA, add oral if need at 4wks, add PO steroid
Left-sided -> rectal ASA, add oral (can swap top for steroid), oral steroid and oral ASA
Extensive -> rectal ASA and oral ASA, add oral steroid
Severe-> hospital, IV steroids, add IV ciclosporin
UC Maintenance
Proctitis -> top ASA (+/-) oral ASA
Left sided/ extensive -> oral ASA
Severe or 2+ in year -> oral Azathioprine or mercaptopurine
Crohn’s Management
Inducing Remission
-> Steroids, 5-ASA, add azathioprine or mercaptopurine, infliximab if fistula/ refractory
Maintenance
-> Azathioprine or mercaptopurine
Perianal fistulae
- MRI, metronidazole, draining seton if complex
Abscess
- incision and drain with Abx, draining seton
A1AT deficiency
AR, Chr14, normally protects cells from neutrophil elastase
= emphysema in lower lobes, cirrhosis and HCC in liver, cholestasis in kids
Inv - spirometry (obstructive), A1AT conc
-> no smoking, physio, BD, lung vol reduction surgery, transplant
Gilberts Syndrome
AR, UDP glucuronosyltransferase deficiency.
BR not conjugated so get unconjugated hyperbilirubinemia (not in urine)
= jaundice when stressed, ill or exercising
No treatment
Upper GI bleed - Scoring
Glasgow-Blatchford - manage as in/outpatient
Rockall - after endoscopy, % of chance of rebleed and mortality
Management of Variceal Upper GI Bleed
Terlipressin and proph Abx
Endoscopy <24hrs - band ligation
If uncontrolled use Sengstaken Blakemore tube
TIPSS if all else fails
Prophylaxis of variceal - propranolol
TIPSS
Connection between the hepatic and portal vein
Blood route that bypasses the liver (v portal HTN)
Management of Non-Variceal Upper GI bleed
Endoscopy <24hrs
PPI given if evidence of GI bleeding and stigmata of recent haemorrhage on endoscopy
Gallstone Ileus
Small bowel obstruction 2nd to impacted gallstone, through GB-duodenum fistula
= vomiting, pain, distension, pneumobillia on XR
Don’t touch the GB
Inguinal Hernias
Most common abdo wall hernias, 95% M
= superomedial to pubic tubercle, disappears lying/ pressure, aching, rarely strangulate
Direct - defect in posterior wall of inguinal canal
Indirect - via deep inguinal ring (patent processus)
-> treat if med fit, open unilateral or lap bilateral
treat infant if presenting in first months of life (high risk of strangulation)
