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GI & Surgery Flashcards

1
Q

Achalasia

A

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

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2
Q

Pharyngeal Pouch

A

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

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3
Q

Oesophageal Cancer

A

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

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4
Q

Plummer-Vinson syndrome

A

Triad of iron deficient anaemia, dysphagia (oes webs) and glossitis

-> iron supp, web dilation

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5
Q

Other Causes of Dysphagia

A

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

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6
Q

GORD

A

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

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7
Q

Management of GORD

A

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

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8
Q

Mesenteric Ischemia

A

RF - age, AF, cancer, CVD RF and cocaine (ischemic colitis).

Acute
= severe sudden abdo pain&raquo_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

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9
Q

Biliary Colic

A

^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

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10
Q

Acute Cholecystitis

A

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

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11
Q

Gallstone complications

A

Mucocele
Abscess/ empyema (swinging fever, US +/- CT)
Gallstone ileus (remove stone, don’t touch GB)

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12
Q

Ascending Cholangitis

A

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

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13
Q

Drugs causing cholestasis

A

COCP
Fluclox, co-amoxiclav and erythromycin
Testosterone, anabolic steroids
Sulphonylurea
Fibrates
Chlorpromazine

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14
Q

Drugs causing hepatocellular picture

A

Paracetamol
Phenytoin
Sodium valproate
Statins
Alcohol
Amiodarone
Methyldopa
MAOI
TB drugs
Nitrofurantoin

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15
Q

Chronic Pancreatitis

A

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

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16
Q

Acute Pancreatitis

A

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

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17
Q

Glasgow scoring system

A

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

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18
Q

Acute Pancreatitis - Causes

A

I GET SMASHED

Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion
Hyperlipidaemia
ERCP
Drugs - azathioprine, mesalazine, thiazides and furosemide

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19
Q

Diarrhoea ABG

A

Anion Gap = all positive ions - negative ions Normally 10-18

Diarrhoea
Loss of bicarb and K from GI tract - hypokalemia metabolic acidosis

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20
Q

Hep A

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

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21
Q

Hepatitis B

A

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

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22
Q

Hep B Serology

A

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

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23
Q

Anal Fissure

A

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

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24
Q

Primary Biliary Cholangitis

A

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

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25
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
26
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
27
UC Maintenance
Proctitis -> top ASA (+/-) oral ASA Left sided/ extensive -> oral ASA Severe or 2+ in year -> oral Azathioprine or mercaptopurine
28
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
29
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
30
Gilberts Syndrome
AR, UDP glucuronosyltransferase deficiency. BR not conjugated so get unconjugated hyperbilirubinemia (not in urine) = jaundice when stressed, ill or exercising No treatment
31
Upper GI bleed - Scoring
Glasgow-Blatchford - manage as in/outpatient Rockall - after endoscopy, % of chance of rebleed and mortality
32
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
33
TIPSS
Connection between the hepatic and portal vein Blood route that bypasses the liver (v portal HTN)
34
Management of Non-Variceal Upper GI bleed
Endoscopy <24hrs PPI given if evidence of GI bleeding and stigmata of recent haemorrhage on endoscopy
35
Gallstone Ileus
Small bowel obstruction 2nd to impacted gallstone, through GB-duodenum fistula = vomiting, pain, distension, pneumobillia on XR Don't touch the GB
36
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)
37
Vit C deficiency
Ascorbic acid, for collagen synthesis Found naturally in citrus fruits, tomatoes, cauliflower, brocoli, cabbage and spinach = ecchymosis and easy bruising, poor wound healing, bleeding gums, lose teeth, arthralgia, malaise
38
C.diff
Gram-positive rod, produces exotoxin RF - clindamycin, cephalosporins, PPIs Classification: Mild - normal WCC Moderate - WCC <15 and 3-5 loose stools Severe - WCC >15, temp >38.5, severe colitis evidence Life threatening - v BP, ileus, toxic megacolon Inv - stool toxin, antigen only shows exposure
39
Management of C.diff
First episode -> oral vancomycin, fidaxomicin 2nd, oral vanc +/- IV met 3rd Recurrent <12wks -> fidaxomicin Life-Threatening -> oral van + IV met
40
C.diff drugs to stop
Stop antimotility drugs and anti-peristaltic Opioids - inc risk of toxic mega colon. Other Abx - stop return of normal gut flora
41
Budd-Chiari
Hepatic vein thrombosis Causes - pregnancy, COCP, thrombophilia, polycytheamia RV = sudden severe abdo pain, abdo distension and tender hepatomegaly Inv - doppler flow studies
42
Boerhaave's syndrome
Spont rupture of oesophagus 2nd to vomiting. Normally distal and on the left hand side. = sudden severe chest pain, SC emphysema Inv - CT contrast swallow -> thoracotomy and lavage, surgery if <12 hours, T tube after (controlled fistula)
43
Wilson's
AR, excessive copper deposition, defect in ATP7B gene on chr 13. = onset 10-25yrs, liver in kids, neuro in adults Liver - hepatitis and cirrhosis Neuro - basal ganglia degen (symmetrical Parkinsonism), psych/ behaviour issues, asterixis, chorea, dementia, double panda sign (MRI) Keyser Fleisher - brown rings in iris, Cu in Descemet membrane Blue nails Fanconi syndrome (RTA) Inv - slit lamp, v serum caeruloplasmin, v total copper, ^free copper, genetic analysis confirms, 24hrs urinary copper, biopsy -> penicillamine or trientine hydrochloride
44
Raised ALP
Biliary obstruction - gallstone, cholangitis, cancer, stricture, fluke, PSC, pancreatitis Liver disease Paget's Bone mets Osteomalacia Hyperparathyroid/ thyroid Renal failure Pregnancy and growing kids
45
Haemochromatosis
AR, Chr 6 HFE gene, 1 in 10 Europeans carr = asymp early, fatigue, erectile dysfunction, arthritis (hands), DM, liver, hypogonadism, bronze skin and dilated CM (reversable) Inv - ^transferrin saturation, ^ferritin, v TIBC, MRI, genetic testingof family -> venesection (keep transferrin sat <50% and ferritin <50), deferoxamine 2nd
46
Peritoneal Dialysis
RRT, younger pts/ less hospital visits Continuous Ambulatory Peritoneal Dialysis (CAPD) involves four 2L exchanges/day Comp - peritonitis (staph epidermidis or aureus) -> vancomycin and ceftazadime
47
Ascites
Serum ascites albumin gradient (>/< than 11g/L) Above: portal HTN Liver - cirrhosis, mets, alcohol Cardiac - constrictive pericarditis, RHF Budd chiari, myxoedma Below: Low albumin - nephrotic, malnutrition Infection - TB Pancreatitis, bowel obstruction -> fluid restrict if low sodium, reduce sodium in diet, spironolactone If tense (painful) use large volume paracentesis with albumin cover If protein in fluid <15 offer ciprofloxacin for Ab prophylaxis
48
SBP
Form of peritonitis usually seen in patients with ascites secondary to cirrhosis (^^E.coli) = ascites, abdo pain, fever Inv - paracentesis (neutrophils >250) -> IV cefotaxime Abx prophylaxis if ascites + prev. SBP or fluid protein <15 (with child pugh 9+ or HRS) - Oral ciproflox
49
FAST Scan
US, used in trauma to assess the extent of free fluid in the chest, peritoneal or pericardial cavity.
50
IBS
= abdo pain, bloating, change in bowel habit >6mths Inv - FBC, ESR/CRP, coeliac screen Pain - antispasmodics Constipation - laxatives (not lactulose), if fails try linaclotide Diarrhoea - loperamide If above not working try TCA
51
Omeprazole vs Lansoprazole
Omeprazole has an interaction with clopidogrel whereas the latter does not
52
Management of Nausea in Migraine
Pro-kinetic agents are used to help relieve gastric stasis and slow the transit and absorption of the drug used in acute migraine attacks E.g., metaclopramide
53
Long term feeding options
Can stomach function? Yes; Short term - NG/ND/ NJ tube. If long term then use PEG tube No: Short term - peripheral parenteral nutrition Longer term - central parenteral nutrition
54
Investigating IBD
Normally a colonoscopy is best If severe colitis UC is investigated with flexy sig due to risk of perf. Note colitis is the finding. In history rare sign but may be incontinence.
55
Hartmanns procedure
Used in emergency obstruction caused by a cancer. This is because anastomosis is not used in emergency. In this procedure there is removal of the obstructed segment (it is the sigmoid and sometimes part of rectum - proctosigmoidectomy) and then an end colostomy is made
56
Gastric Cancer
RF - older, M, H. pylori, atrophic gastritis, salt and salt-preserved foods, nitrates, smoking, blood group A = vague/ epigastric abdo pain, dyspepsia, weight loss, anorexia, n+v, left supraclavicular lymph node (Virchow's), periumbilical nodule (Sister Mary Joseph's) Inv - OGD with biopsy (signet ring cells), CT staging -> endo mucosal resection, partial/ total gastrectomy, chemo
57
Solitary Rectal Ulcer Syndrome
Cause - chronic constipation = pain, bleeding Inv - histology shows mucosal thickening with collagen deposition (fibromuscular obliteration)
58
Haemorrhoids
Enlarged vascular cushions, internal or external depending (dentate line), 3, 7, 11 Graded on ability to prolapse 1 - No Prolapse 2 - Prolapse but go back on own 3 - Prolapse and need to be reduced by self 4 - Always prolapsed
59
Management of Haemorrhoids
Soften stool (inc fibre and fluid) Top anaesthetics/ steroids Rubber band ligation Surgery for large symp not responding Thrombosed - acutely painful and purplish. Excise if present within first 72 hours. Otherwise use stool softeners and ice packs
60
Pathology of Alcoholic Liver Disease
1. Alcohol related fatty liver 2. Alcoholic hepatitis - in acute disease steroids can be used to manage 3. Cirrhosis - scar tissue replaces healthy tisssue
61
Stigmata of CLD
Jaundice hepatomegaly Spider Naevi Palmar Erythema Gynaecomastia Bruising Ascites Caput Medusae Astrexis
62
Liver Cirrhosis
Scar tissue replaces normal liver tissue increasing resistance in vessels = portal hypertension Causes - alcohol, NAFLD, hep B and C In decompensated all LFTs are deranged. In alcoholic AST > ALT and in NAFLD opposite ELF - first line in assessing cirrhosis in NAFLD US - if above not available. Fibroscan / Transient elastography - every 2 years if heavy alcohol, Hep C, Alcoholic liver, NAFLD or chronic Hep B to assess level of fibrosis
63
Scoring systems in Liver Disease
Child Pugh: severity of cirrhosis and prognosis. Each scored out of 3 Billirubin Albumin INR Ascites Encephalopathy MELD: Used every 6 months in those with compensated cirrhosis to give 3 month mortality BR, creatinine, INR
64
Cirrhosis: Monitoring
US and AFP - 6 months Endoscopy - 3 years MELD - 6 month
65
Malnutrition - Cirrhosis
Cirrhosis impacts the metabolism of proteins in the liver = decreased production. Also impacts storage and release of glycogen Management - low sodium and high protein / calorie
66
Portal HTN - Cirrhosis
Portal vein delivers blood to the liver (from SMV and splenic vein) In cirrhosis there is inc resistance in blood flow = inc back flow of pressure. Causes vessels at anastomosis sites to become swollen: Gastro-oesophageal junction Ileocaecal Junction Rectum Anterior abdo wall - caput medusae
67
Ascites - Cirrhosis
-Fluid in peritoneal cavity. Caused by portal HTN. This drop in circulating volume can lead to reduced Bp entering kidneys. This is sensed and so renin released. Via aldosterone more sodium and fluid is reabsorbed. -> low sodium diet, aldosterone antagonists, parecentesis
68
Hepatorenal Syndrome
Portal HTN means the vessels in the portal system are stretched and dilated. Blood pools here This means less blood volume in the kidneys. RAAS is activated which causes renal vasoconstriction. - blood starvation
69
Hepatic Encephalopathy
Liver cirrhosis prevents the metabolism of ammonia. Also because of portal HTN there is collateral vessels that form between portal and systemic circulation. Means ammonia can bypass the liver and enter systemic system 1 - irritable 2 - confusion / inappropriate 3 - restless / incoherent 4 - coma Lactulose given to manage. Can also give rifaximin - reduces bacteria producing lactulose.
70
NAFLD
Most common cause of liver disease in developed world, hepatic manifestation of metabolic syndrome Steatosis -> steatohepaitits -> fibrosis and cirrhosis RF - obesity, T2DM, high lipids, smoking, sudden weight loss, jejunoileal bypass Inv - ALT>AST, US (^echogen), enhanced liver fibrosis blood -> weight loss, smoking cessation, control of comorbidities
71
Liver Cancer
HCC (80%) RF - (cirrhosis) hep B, hep C, alcohol, haemochromatosis, PBC, A1AT US+/- AFP Cholangiocarcinoma (20%) RF - PSC = persistent biliary colic, palpable RUQ mass CA19-9
72
Liver Transplant
Used in Acute liver failure (hepatitis or paracetamol) or chronic liver failure. Contra - sig comorbid, active hepatitis, end stage HIV and active alcohol use (6m abstinence) Kings college LT guidelines for Paracetamol OD
73
Infective Causes of Diarrhoea
Campylobacter - recent travel. Blood stools. E.coli - recent travel. Stomach cramps and non- bloody diarrhoea.
74
Hernia terms
Strangulated: irreducible, base cuts off blood supply = sig pain and tenderness Incarcerated: can't be reduced back but is not painful.
75
Weird Hernias
Richters - Only part of the bowel wall and lumen herniate but the other half does not. Madyls - two different parts of bowel have herniated Spigelian - Between the lateral border of the rectus abdominus and line seminlunaris. Diastasis Recti - Normally after pregnancy. Widening of the line alba
76
RIF pain on PR
Appendicitis
77
Investigation after anastamosis
Gastrografin enema is used to see if the joining has healed properly and ensure no leaking.
78
Hyatid Cysts
Common in Middle Eastern and Mediterranean countries They form an outer capsule with multiple daughter cysts US is often used first line but CT is the best to differentiate from diff kinds of cysts Mebendazole and surgery to treat
79
Blood gas in vomiting
Metabolic alkalosis - due to H+ ions being lost - with a low K+
80
Autoimmune Hepatitis
Type 1 - Both Adults and Kids. ANA and anti smooth muscle Type 2 - children. AL/KM (anti liver / kidney) Type 3 - middle aged adults. soluble liver antigen = CLD, fever, jaundice, amenorrhea All have raised IgG, biopsy (inflam, necrosis) -> steroids, IS, transplant
81
Small Bowel Bacterial Overgrowth Syndrome
RF - DM, scleroderma and neonates with GI issues = chronic diarrhoea, bloating and pain Inv- hydrogen breath test -> rifaximin to treat
82
Dyspepsia referral
All with dysphagia All with upper abdo mass = stomach cancer Aged over 55 with weight loss and one of; reflux dyspepsia Upper abdo pain
83
Coeliac Disease
AI inflam, small bowel (j), autoantibodies to gluten protein (gliadin) RF: F, FHx, HLA-DQ2/8 = fatigue, diarrhoea, steatorrhea, n+v, bloating, abdo pain, weight loss, vit def, dermatitis herpetiformis (itchy blistering extensor, IgA in dermis) Eat gluten 6 wks -> total IgA, anti-TTG, anti-endomysial, endoscopy + biopsy (villus atrophy, crypt hypertrophy, lymph infiltration) Comp - hyposplenism (peum vac 5yrly), enteropathy-associated T-cell lymphoma of SI
84
Bowel obstruction
Cause - adhesions (small), tumour (large) Inv - abdo XR, CT definitive Dilated if small bowel is >3cm diameter, >9cm for caecum, 8cm for ascending colon, and >6cm for recto-sigmoid NBM, drip and suck
85
Unknown GI bleed
FBC, coag, crossmatch, G&S!! PR and proctoscopy OGD CT angiogram (triple phase)
86
Colonic bleed
Resection or interventional embolization (tertiary)
87
Wound dehiscence
Saline soaked gauze, senior input, prep for surgery (bloods, NBM)
88
Surgical ward round
History, exam, look at notes ? NEWS, bloods, fluid chart, drugs Look at drains, wounds, NG, catheter, stoma Ask about pain, n+v, eating, drinking, bowels (flatus), urine, breathing, mobilisation
89
Barrett's
Reflux of acid causes metaplasia of squamous epithelium to columnar. RF - GORD, 7M:F, smoking, central obesity Management - high-dose PPI, endoscopy every 3-5 years if metaplasia, if dysplasia seen then RF ablation or endo resection
90
Pancreatic Cancer
80% adenocarcinoma, at head, present late RF - age, smoking, DM, chronic panc, HNPCC, MEN, BRCA2, KRAS = painless jaundice, pale stool, dark urine, pruritus, GB/ epigastric mass, DM, atypical back pain, migratory thrombophlebitis (Trousseau) Inv - US, high res CT best (double duct - CBD and panc) -> Whipple's, adjuvant chemo, ERCP and stent for palliative
91
H. Pylori Eradication
Gram-ve bacteria Link - peptic ulcer, 95% of duodenal ulcers, 75% of gastric ulcers, gastric cancer, B cell lymphoma of MALT tissue, atrophic gastritis Inv - urea breath test (no Abx for 4wk, no PPI for 2wk, can check eradication) -> 7d PPI + amoxicillin + clarithromycin/ metronidazole

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