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GI surgery Flashcards

1
Q

Why is a urine dipstick done?

A

Infection - WBC, RBC, nitrites
Haematuria
Pregnancy

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2
Q

Why might you do a blood gas for a GI presentation?

A

If considering gastric outflow obstruction which would make you alkalotic

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3
Q

What can cause a high haemoglobin?

A

Dehydration
Peritonitis
Pericarditis

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4
Q

What can cause a raised haematocrit?

A

Dehydration due to excess vomiting

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5
Q

What can elevate WCC?

A

Infection
Active IBD
Bowel obstruction

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6
Q

What does a raised urea and raised creatinine indicate?

A

Dehydration

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7
Q

What does a raised urea and normal creatinine indicate?

A

GI haemorrhage

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8
Q

What can cause a low chloride?

A

Gastric outflow obstruction due to loss of hydrochloric acid in vomitus

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9
Q

Why is it important to measure TFTs?

A

Thyrotoxic can cause diarrhoea

Myxoedema can cause constipation

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10
Q

What is CEA (carcinoembryonic antigen) a marker for?

A

Colonic cancer

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11
Q

What is CA125 a marker for?

A

Ovarian cancer

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12
Q

What is alpha-fetoprotein a marker for?

A

Primary hepatoma and teratoma

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13
Q

What is CA19-9 a marker for?

A

Non specific

Rises in pancreatitis and pancreatic cancer

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14
Q

What types of USS can be done?

A

KUB for renal tract pathology
Biliary tree and liver for gallstone disease, liver metastases or cysts
Ovaries, Fallopian tube and uterus
Endoscopic - assess and stage malignancy in upper GI tract
Transoeosphageal ultrasonography

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15
Q

What GI problems would you be looking for on an erect CXR?

A

Subphrenic free gas indication perforation of hollow viscus
Subphrenic bubbles indicating subphrenic abscess
Lower lobe pneumonia

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16
Q

How can you differentiate between a dilated large and small bowel on AXR?

A

Small bowel is arranged more centrally and has bands that transverse its entire diameter (valvulae conniventes)
Large bowel is peripheral with haustra

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17
Q

What might an AXR with gas in the biliary tree indicate?

A

Gallstones
Ileus
Cholangitis

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18
Q

What is suggested by an AXR with no air in rectum?

A

Proximal obstruction

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19
Q

If there is a ground glass appearance on AXR what does this suggest?

A

Ascites

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20
Q

When is CT better than US?

A

Assess bleeding in unstable patients

Imaging pancreas, metastases, other intra-abdominal malignancies

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21
Q

When would you do a barium or gastrografin enema?

A

Mechanical obstruction

Visualise colon proximal to stricture that a colonoscope can’t pass through

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22
Q

When is a barium swallow indicated?

A

Vomiting to look for oesophageal and gastric pathology

Dysphagia

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23
Q

When is a barium meal indicated?

A 
Hiatus hernia
Reflux
Large gastric ulcer and tumour
Scarring of duodenum
Imaging masses arising in small bowel
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24
Q

What does a rigid sigmoidoscopy visualise?

A

Rectum and lower sigmoid

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25
What does a flexible sigmoidoscopy visualise?
Colon and splenic flexure
26
What does a colonoscopy visualise?
Up to the caecum
27
What is an OGD (oesophagogastroduodenoscopy) used to identify?
Gastritis Gastric cancer Duodenal ulcer Oesophageal cancer
28
What is oesophageal manometry and pH monitoring used for?
Coordination and strength of peristaltic movements in the oesophagus and sphincter pressure Identify cause of benign stricture of oesophagus
29
Where would foregut pathology cause pain?
Epigastric region
30
What comes from the foregut?
``` Oesophagus Upper duodenum StomachLiver Gallbladder and bile ducts Pancreas ```
31
Where would midgut pathology cause pain?
Central region
32
What comes from the midgut?
``` Appendix Lower duodenum Jejunum Ileum Caecum Ascending colon Proximal 2/3 transverse colon ```
33
Where does hindgut pathology cause pain?
Suprapubic
34
What comes from the hindgut?
``` Distal 1/3 transverse colon Descending colon Sigmoid colon Rectum Anus ```
35
What can cause pain in right upper quadrant?
``` Cholecystitis Pyelonephritis Hepatitis Ureteric colic Pneumonia ```
36
What causes pain in epigastric region?
Peptic ulcer Cholecystitis Pancreatitis MI
37
What causes pain in left upper quadrant?
``` Gastric ulcer Pyelonephritis Ureteric colic Pneumonia Splenic disorder ```
38
What causes pain in lower right quadrant?
``` Appendicitis IBD Diverticulitis Inguinal hernia Ureteric coli UTI Gynaecological Testicular torsion ```
39
What causes pain in periumbilical region?
Small bowel obstruction Large bowel obstruction Appendicitis AAA
40
What causes pain in lower left quadrant?
``` Diverticular disease IBD Inguinal hernia Ureteric colic UTI Gynaecological or testicular torsion ```
41
What causes diffuse abdominal pain?
``` Acute pancreatitis Diabetic ketoacidosis Gastroenteritis Mesenteric ischaemia Peritonitis Intestinal obstruction ```
42
What is peritonitic facies?
Pale sweaty face with sunken eyes and grey complexion
43
What might you find on a rectal examination and what would it suggest?
Tenderness - pelvic appendicitis Boggy swelling of pelvic abscess Large prostate gland causing urinary retention Rectal carcinoma
44
What might you find on a vaginal examination and what would it suggest?
Vaginal discharge - salpingitis Cervical tenderness or excitation in salpingitis or ectopic pregnancy Retained tampon causing toxic shock Pelvic mass - ovarian cyst, pelvic abscess, fibroid uterus
45
What are the signs a patient is in hypovolaemic shock?
Tachycardia Hypotensive Pale and clammy Thready pulse
46
What are the signs of generalised peritonitis?
Lying very still, look unwell Tachycardia and potential hypotension Guarding and rebound tenderness Rigid abdomen
47
What are the signs of an ischaemic bowel?
Diffuse constant pain that is out of proportion to clinical signs Acidotic, raised lactate, physiologically compromised Examination will be unremarkable
48
How do you diagnose an ischaemic bowel?
CT with contrast
49
What is colic pain?
Abdominal pain that crescendos to become very severe then goes away e.g. ureteric obstruction or bowel obstruction
50
Why does peritonitis occur?
Inflammation of a viscus that irritates visceral and parietal peritoneum
51
What can cause difficulty with opening bowels?
Stenosing carcinoma of the colon Diverticular stricture Obstructing lesion of the rectum or anal canal Hypothyroidism
52
What does fresh rectal blood indicate?
Anorectal disease | Carcinoma, polyp, perianal disease
53
What does dark rectal blood indicate?
Bleeding is in sigmoid colon or above
54
What does rectal blood that is mixed with stool indicate?
Bleeding is above sigmoid colon
55
What does rectal mucus with no blood indicate?
IBS
56
What can causes tenesmus?
Rectal mass lesion e.g. carcinoma or large polyp | IBD affecting the rectum
57
What family history might you want to ask about if they have a change in bowel habits?
Familial polyposis coli Carcinoma of the bowel IBD
58
What infections from foreign travel could cause a change in bowel habits?
``` Giardiasis Shigellosis Salmonellosis Campylobacter infection Amoebic dysentery Typhoid Cholera ```
59
What drug history might you want to consider if the patient has a change in bowel habits?
Constipation - opiates, anticholinergics, antidiarrhoeals | Diarrhoea - laxatives, antibiotics
60
On examination you find pigmentation of the buccal mucosa. What does this suggest?
Peutz-Jeghers syndrome
61
What investigations would you want to do for a change in bowel habits?
Bloods - FBC, TFTs, coeliac screen, CRP and ESR, CEA antigen Stool culture and microscopy Endoscopy /sigmoidoscopy / colonoscopy Double contrast barium enema
62
What are the differential diagnoses of constipation?
``` Small or large bowel obstruction - strictures Functional e.g. IBS Drugs - opioids, analgesics Hypothyroidism Local anorectal dysmotility - anismus Neurological disorder ```
63
What are the differential diagnoses of diarrhoea?
Acute - infectious - traveller's diarrhoea - drugs e.g. antibiotics, laxatives Chronic - hyperthyroidism, thyrotoxicosis, anxiety - small bowel disease e.g. Crohn's, coeliac - large bowel disease e.g. UC, Colon cancer, IBS
64
What can cause PR bleeding?
``` Diverticulosis Ischaemic or infective colitis Haemorrhoids Malignancy Angiodysplasia IBD Radiation proctitis ```
65
What might you see on inspection with presenting anorectal pain?
``` Excoriated inflamed skin Skin tags Abscess Small perianal opening discharging pus or faecal matter Thrombosed piles Perianal haematoma ```
66
What is the likely site of the problem if vomiting undigested food immediately after eating with associated dysphagia?
Oesophagitis | Gastric cause
67
What is the likely site of the problem if vomiting partially digested food soon after eating with epigastric pain?
Stomach duodenum
68
What is the likely site of the problem if vomiting bilious with partially digested food, a few hours after eating and associated abdo distension and pain?
Small bowel
69
What is the likely site of the problem if vomiting billions, no food and associated dizziness?
Neurogenic | Vestibular
70
What are some differential diagnoses for vomiting?
Mechanical obstruction in oesophagus, stomach, small or large bowel Obstruction in appendix, biliary ducts, Fallopian tube or ureter Irritation of nerves or peritoneum or mesentery - gastritis, perforation of viscus, intra-abdominal sepsis and totted ovarian cyst Chemically induced CNS disorders - drugs and alcohol, vestibulitis, motion sickness
71
What is the differential diagnoses for haematemesis and melaena?
``` Duodenal ulceration Gastric ulceration Gastritis Gastric cancer Oesophagitis Mallory-Weiss tear Oesophageal malignancy Oesophageal varices ```
72
What are oesophageal varies?
Dilatation of porto-systemic venous anastomoses in oesophagus
73
What are the differential diagnoses of dysphagia?
``` Mechanical - oesophageal or gastric malignancy - benign oesophageal stricture - extrinsic compression - pharyngeal pouch - foreign body - oesophageal web Neuromuscular - post-stroke - achalasia - diffuse oesophageal spasm - myasthenia gravis - myotonic dystrophy ```
74
What are the risk factors for dyspepsia?
``` Chronic gastritis Hypochlorhydria H.pylori infection Previous partial gastrectomy Diet Smoking ```
75
What drugs do you want to ask about in abdominal distension?
Opioid analgesics - constipation Psychotropic drugs - pseudo-obstruction of bowel Alpha blockers can cause urinary retention Corticosteroids which can cause deposition of body fat in central distribution
76
What are the differential diagnoses of abdominal mass and RUQ pain?
Cancer of hepatic flexure of colon Distended gallbladder Hepatomegaly
77
What are the differential diagnoses of epigastric mass?
``` Gastric tumour Transverse colon tumour Hepatomegaly Pancreatic tumour Pancreatic pseudocyst ```
78
What are the differential diagnoses of LUQ mass?
Cancers of descending colon Splenomegaly Pancreatic pseudocyst
79
What are the differential diagnoses of L/R flank mass?
Renal tumour | Polcystic kidney
80
What are the differential diagnoses of suprapubic mass?
Uterus - fibroids, uterine cancer, pregnancy Ovarian mass Distended bladder
81
What are the differential diagnoses of RIF mass?
``` Distended caecum Caecal tumour Appendix mass Crohn's disease Ovarian mass ```
82
What are the differential diagnoses of LIF mass?
Sigmoid colon tumour Diverticular abscess or mass Ovarian mass Constipation
83
What type of jaundice do dark urine and pale stools indicate?
Obstructive jaundice
84
What does a rapid and painful jaundice indicate?
Common bile duct stones
85
What does gradual jaundice with preceding flu-like illness indicate?
Infectious hepatitis
86
What does jaundice with an insidious onset indicate?
Carcinoma of pancreas
87
What does caput medusae indicate?
Portal hypertension
88
What does a jaundice without raised bilirubin indicate?
Haemolytic jaundice | Hyperbilirubinaemia e.g. Gilbert syndrome or Crigler-Najjar syndrome
89
What might you see on USS of a patient presenting with jaundice?
``` Dilated biliary ducts associated with biliary obstruction Common bile duct stones Architectural disturbance of liver Metastases Pancreatic swelling or masses ```
90
What are the differentials of weight loss?
``` Malignancy Colon cancer IBD Coeliac disease Thyrotoxicosis Anorexia / bulimia nervosa, depression, stress Malnutrition Substance misuse End organ failure Diabetes mellitus type 1 Chronic inflammatory disease Chronic infection e.g. TB HIV / AIDs Severe cardiorespiratory disease Swallowing difficulties e.g. oesophageal stricture ```
91
When is a colonoscopy indicated?
Any rectal bleeding in patient over 50 years Symptoms suggestive of colonic bleeding Iron deficiency anaemia Persistent changes in bowel habit Surveillance of IBD Population screening for colorectal carcinoma
92
When is a colonoscopy contraindicated?
Consent can't be given Suspected or known perforation Documented acute diverticulitis Fulminant colitis
93
What are the complications of a colonoscopy?
``` Bleeding Perforation Infection Sedative complications Prep complications ```
94
When is a CT colonography contraindicated?
``` Active colonic inflammation Symptomatic colon-containing abdominal wall hernia Recent acute diverticulitis Recent colorectal surgery Recent endoscopic biopsy Colonic perforation Bowel obstruction ```
95
What are the complications of a CT colonography?
``` Colonic perforation Radiation exposure Incidental extracolonic findings Vasovagal reaction due to pain induced by colonic distension Preparation complications ```
96
What is a proctocolectomy?
All of colon and rectum are removed
97
What are the types of colonic polyps?
``` Neoplastic - adenomas - tubular / villous / tubulovillous Non-neoplastic - hyperplastic - inflammatory - hamartomas - lymphoid ```
98
What is familial polyposis coli?
Autosomal dominant condition in which hundreds of adenomas develop through colon and rectum during 2nd decade of life
99
What are the symptoms of colonic polyps?
``` Asymptomatic Rectal bleeding Mucus discharge Tenesmus Change in bowel habit Anaemia Fatigue ```
100
What are the differentials of colonic polyps?
Colorectal cancer Haemorrhoids Anal fissure IBD
101
What is the management of colonic polyps?
Surgical resection TEMS (transanal endoscopic microsurgery) TAMIS (transanal minimally invasive surgery) Open surgery / laparoscopic / robotic
102
Describe the screening for colorectal cancer
50-74 year olds invited ever 2 years Faecal occult blood test Being replaced by faecal immunochemical test
103
What are the risk factors for colorectal cancer?
``` Male Increasing age Smoking Alcohol Obesity Family history IBD Adenomatous polyps Familial polyposis coli or Gardener's syndrome Low fibre diet ```
104
What are the clinical features of colorectal cancer?
``` Change in bowel habits Rectal bleeding Weight loss if metastatic Abdominal pain Iron deficiency anaemia ```
105
What would be the signs of a right sided colon cancer?
Abdominal pain Occult bleeding / anaemia Mass in RIF
106
What would be the signs of a left sided colon cancer?
``` Rectal bleeding Change in bowel habit Mucus Tenesmus Mass in LIF or on PR exam ```
107
What are the differential diagnosis of colorectal cancer?
IBD | Haemorrhoids
108
What is removed in a right / extended right hemicolectomy?
Removal of right side of colon | Ileocolic, right colic and right branch of middle colic vessels
109
What is removed in a left hemicolectomy?
Removal of left side of colon | Left branch of middle colic vessel, inferior mesenteric vein and left colic vessels
110
What is removed in a sigmoid colectomy?
Middle part of colon and inferior mesenteric artery
111
What are the clinical features of Crohn's disease?
``` Abdominal pain Diarrhoea Rectal bleeding Mucous discharge Perianal problems Oral aphthous ulcers Systemic symptoms - malaise, anorexia, malabsorption ```
112
What are the extra intestinal manifestations of Crohn's?
MSK - enteropathic arthritis, metabolic bone disease Skin - erythema nodosum, pyoderma gangrenous Eyes - episcleritis, anterior uveitis Hepatobiliary - cholangiocarcinoma Renal stones
113
What are the abnormal bloods in Crohn's disease?
Anaemia, raised WCC Low albumin Raised CRP
114
How can you differentiate between IBD and IBS?
Faecal calprotectin test which is raised in presence of inflammation
115
What would you see on a colonoscopy of Crohn's disease?
Cobblestoning of bowel
116
How will you manage an acute Crohn's episode?
``` Fluids, nutritional support and heparin Anti-thrombotic stocks Corticosteroid therapy Add immunosuppressive e.g. azathioprine or mesalazine or methotrexate Add biologics e.g. infliximab ```
117
Why should anti-motility drugs be avoided in Crohn's?
They can precipitate toxic megacolon
118
What are the complications of Crohn's disease?
``` Fistula Stricture formation which can lead to bowel obstruction Recurrent perianal abscess GI malignancy Obstruction Malabsorption, anaemia, weight loss Osteoporosis Increased risk of gallstones Increased risk of renal stones ```
119
What histological changes occur in UC?
inflammation of mucosa and submucosa Crypts of Lieberkuhn are inflamed and crypt abscesses develop Goblet cell hypoplasia
120
What are the clinical features of UC?
``` Bloody diarrhoea PR bleeding and mucus discharge Increased frequency Urgency of defecation Abdominal pain Tenesmus Malaise, anorexia, weight loss ```
121
What are the differentials of UC?
``` Crohn's Chronic infection Mesenteric ischaemia Radiation colitis Malignancy IBS Coeliac disease ```
122
How will you manage an acute attack of UC?
Corticosteroid therapy e.g. prednisone Add immunosuppressive agent e.g. azathioprine or methotrexate Add biological agent e.g. infliximab Give bisphosphonate while on corticosteroids
123
What are the complications of UC?
Toxic megacolon Colorectal carcinoma Osteoporosis Primary sclerosising cholangitis
124
What are the side effects of steroids?
``` Weight gain and abnormal fat distribution Thin skin, easy bruising, striae Hirsutism or hair loss Osteoporosis Proximal myopathy Menstrual irregularities Hypertension Hypokalaemia Impaired glucose tolerance Depression Growth and developmental delay in children ```
125
What are the side effects of azathioprine?
``` Myelotoxicity Hepatotoxicity Pancreatitis GI intolerance Susceptibility to infections Lymphoma Skin cancer ```
126
What tests might you want to do for IBS?
``` FBC Coeliac serology CRP & ESR TSH, FOBT, Iron Faecal calprotectin Sigmoidoscopy or colonoscopy ```
127
What are the 4 manifestations of diverticular disease?
Diverticulosis - presence of diverticula Diverticular disease - symptomatic diverticula Diverticulitis - inflammation of diverticula Diverticular bleed
128
What are diverticula?
Mucosa covered by layer of peritoneum within neck and large pouch
129
What are the risk factors for diverticular disease?
``` Lack of fibre in diet Smoking Obesity Family history NSAIDs ```
130
Describe the characteristics of diverticular pain
``` Intermittent, colicky lower abdominal pain Relieved by defecation Altered bowel habit Nausea Flatulence ```
131
Describe the symptoms of diverticulitis
``` Sharp LIF pain worsened by movement Localised tenderness and peritonitis in LIF Systemically unwell Palpable mass Abdominal distension ```
132
What are the symptoms of a vesicolic fistula?
Cystitis, pneumaturia and recurrent UTIs
133
Why can't you perform a flexible sigmoidoscopy in suspected diverticulitis?
Increased risk of perforation
134
What would you see on a CT of suspected diverticulitis?
Thickening of colonic wall Pericolonic fat stranding Abscesses Localised air bubbles or free air
135
How do you manage mild diverticular disease?
Analgesia - avoid constipating agents | Increase oral fluid intake
136
What is the conservative management of acute diverticulitis?
IV antibiotics, usually metronidazole IV fluids Bowel reset Analgesia
137
What is a Hartmann's procedure?
Sigmoid colonoscopy with formation of end colostomy and closure of rectal stump
138
What is the long term management of diverticular disease?
``` High fibre diet and high fluid intake Analgesics Laxatives Anticholinergics Surgery to resect colon ```
139
What are the complications of diverticular disease?
``` Acute diverticulitis Fibrosis Perforation Fistula formation Obstruction Haemorrhage ```
140
What can cause a large bowel obstruction?
``` Polypoid tumour Constipation Malignancy Ischaemia Diverticular or radiation stricture Hernia Volvulus ```
141
What is a volvulus?
Twisting of segment of intestinal tract around a fixed point leading to acute mechanical bowel obstruction
142
What are the symptoms of large bowel obstruction?
Colicky abdominal pain - if this becomes constant it suggests ischaemia Abdominal distension Constipation Vomiting as a late stage
143
What are the signs of large bowel obstruction?
``` Evidence of underlying cause Abdominal distension Focal tenderness Guarding or rebound tenderness Tinkling bowel sounds ```
144
What would you see on an AXR of a large bowel obstruction?
Dilated bowel Peripheral location Haustral lines visible May have concurrent small bowel dilatation if incompetent ileocaecal valve
145
Why is a CT scan more useful than an AXR for large bowel obstruction?
More sensitive Can differentiate between mechanical obstruction and pseudo-obstruction Demonstrate site and cause of obstruction Demonstrate presence of metastases
146
What are the differentials of a large bowel obstruction?
``` Paralytic ileus Small bowel obstruction Toxic megacolon Constipation Endometriosis ```
147
What is the management of a large bowel obstruction?
Conservative - NG tube to decompress bowel, IV fluids, catheter, analgesia Laparotomy colonic resection
148
What are the complications of a colostomy?
``` Retraction Prolapse Herniation Stenosis Bowel obstruction ```
149
What is the aetiology of a small bowel obstruction?
``` Intraperitoneal adhesions Hernia Volvulus Tumour Stricture Intramural haematoma Gallstones, foreign body Crohn's disease Appendicitis ```
150
What are the risk factors for a small bowel obstruction?
``` Prior abdominal or pelvic surgery Abdominal wall or groin hernia Intestinal inflammation e.g. Crohn's History of or increased risk for neoplasm Prior abdominopelvic irradiation History of foreign body ingestion ```
151
What are the symptoms of a small bowel obstruction?
Colicky abdominal pain Vomiting Abdominal distension Absolute constipation
152
What are the signs of a small bowel obstruction?
``` Evidence of underlying cause Dehydration Abdominal distension Focal tenderness Guarding and rebound tenderness Tinkling bowel sounds ```
153
What would be seen on an AXR of a small bowel obstruction?
``` Dilated bowel Central abdominal location Valvulae conniventes visible Partial SBO - gas throughout Complete SBO - no distal gas Complicated SBO - air under diaphragm ```
154
What are the differentials of a small bowel obstruction?
``` Large bowel obstruction Paralytic ileus Toxic megacolon Constipation Infective gastroenteritis Appendicits Pancreatitis ```
155
What are the risk factors for haemorrhoids?
Excessive straining from chronic constipation Increasing age Raised intraabdominal pressure e.g. pregnancy, cough, ascites Pelvic or abdominal masses Family history Cardiac failure Portal hypertension
156
What are the symptoms of haemorrhoids?
``` Painless bright red bleeding following defecation Pruritus ani due to mucous discharge Rectal fullness or anal lump Soiling Prolapse ```
157
What are the differentials of haemorrhoids?
``` Malignancy IBD Diverticular disease Fissure-in-ano Perianal abscess Fistula-in-ano ```
158
What is the management for haemorrhoids?
Conservative - high fibre diet, increase fluids, laxatives, topical analgesia Topic agents e.g. anusol, proctosedyl, diltiazem cream Injection sclerotherapy Barron's bands Cryotherapy and infrared coagulation Haemorrhoidectomy Haemorrhoid artery ligation
159
What does diltiazem cream do to haemorrhoids?
Reduce size of haemorrhoid, reduce anal sphincter tone which increases blood flow and promotes healing
160
When is a haemorrhoidectomy indicated?
Recurrent prolapse Acutely thromboses piles Failure to respond to conservative therapies Unsuitable for banding or injection
161
What are the complications of haemorrhoids?
``` Thrombosis Ulceration Gangrene Skin tags Perianal sepsis ```
162
What is an anal fissure?
Tear in mucosal lining of anal canal characterised by pain on defecation and rectal bleeding
163
What are the risk factors of an anal fissure?
Inflammation or trauma to anal canal - constipation, diarrhoea, vaginal birth, anal sex IBD Chronic disease - extrapulmonary TB, malignancy, HIV
164
What are the clinical features of an anal fissure?
Intense pain post-defecation Pain out of proportion to fissure size Bleeding Itching
165
What are the differentials of an anal fissure?
``` Haemorrhoids Anal fistula Crohn's disease UC Anal cancer ```
166
What is the management of an anal fissure?
``` Reduce risk factors Increase fluid and fibre intake Analgesia Stool softening laxatives Topical anaesthetics - lidocaine GTN cream or diltiazem cream Surgical - botox injections or lateral sphincterotomy ```
167
What are the 4 types of anal fistulae?
Inter-sphincteric Trans-sphincteric Supra-sphincteric Extra-sphincteric
168
What are the risk factors for an anal fistula?
IBD Systemic disease - TB, diabetes, HIV History of trauma to anal region Previous radiotherapy to anal region
169
What are the symptoms and signs of an anal fistula?
``` Recurrent perianal abscess Intermittent rectal pain Intermittent pruritus Intermittent or continuous discharge onto perineum Excoriated or inflamed perianal skin External opening on perineum may be seen ```
170
What is the Goodsall rule for anal fistula?
Clinically predict trajectory of fistula tact depending on location of external opening External opening posterior to transverse anal line means fistula tract will follow a curved course to posterior midline External opening anterior to transverse anal line means fistula tract will follow straight radial course to dentate line
171
What are the differentials of an anal fistula?
Anal abscess Anal fissure Anal ulcer
172
What are the symptoms of an appendicitis?
``` Abdominal pain initially periumbilical then to RIF Vomiting Anorexia Nausea Diarrhoea or constipation ```
173
What would you find on examination of a suspected appendicitis?
``` Tachycardia, tachypnoea Pyrexia Rebound tenderness and percussion pain over McBurney's point Signs of guarding if perforated Rovsing's sign Psoas sign ```
174
What is Rovsing's sign?
RIF pain on palpation of LIF | Indicative of right sided local peritoneal irritation
175
What is psoas sign?
RIF pain with extension of right hip | Suggests inflamed appendix abutting psoas major muscle in retrocaecal position
176
What would you see on a CT of appendicitis?
Enlarged appendiceal diameter with occluded lumen Appendiceal wall thickening Periappendiceal fat stranding Appendiceal wall enhancement
177
What are the complications of an appendicitis?
``` Perforate Generalised peritonitis Surgical site infection Appendix mass Pelvic abscess ```
178
What is the aetiology of pancreatitis?
``` I GET SMASHED Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimune Scorpion venom Hyperlipidaemia / hypothermia / hypercalcaemia ERCP Drugs e.g. azathioprine, NSAIDs or diuretics ```
179
What are the symptoms and signs of acute pancreatitis?
``` Sudden onset severe epigastric pain Nausea and vomiting Epigastric tenderness with guarding Haemodynamic instability due to inflammatory responses Cullen's sign, Grey Turner's sign ```
180
What is included in the modified Glasgow coma score pancreatitis?
``` PO2 <8 Age >55 WCC >15 Ca <2mmol/L Renal function - urea >16mmol/L Enzymes - AST >200, LDH >600 Albumin <32g/L Sugar >10mmol ```
181
What are the differential diagnoses of acute pancreatitis?
``` AAA Renal calculi Chronic pancreatitis Aortic dissection Peptic ulcer disease ```
182
What are the complications of acute pancreatitis?
``` Hypovolaemic shock Haemorrhagic pancreatitis Pseudocyst formation Infected necrosis ARDS SIRS Chronic pancreatitis ```
183
What is the aetiology of chronic pancreatitis?
Chronic alcohol abuse Idiopathic Metabolic - hyperlipidaemia, hypercalcaemia Viral - HIV, mumps, coxsackie Bacterial CF Autoimmune pancreatitis, SLE Obstruction of pancreatic duct - stricture formation, neoplasm Congenital - pancreas divisum, annular pancreas
184
What are the differentials of chronic pancreatitis?
Acute cholecystitis Peptic ulcer disease Acute hepatitis Sphincter of Oddi dysfunction
185
What are the risk factors for peptic ulcer disease?
``` H.pylori NSAIDs Corticosteroid use Previous gastric bypass surgery Physiological stress Zollinger-Ellison syndrome ```
186
What are the symptoms of peptic ulcer disease?
``` Epigastric or retrosternal pain that is exacerbated by eating Nausea Bloating Post-prandial discomfort Early satiety ```
187
What is the difference between gastric and duodenal ulcers?
Gastric are worsened by food, duodenal are relieved by food Gastric peaks at 50yo, duodenal peak at 25-30yo 45% gastric are associated with. H.pylori, 85% of duodenal are associated with H.pylori
188
What are the differentials of peptic ulcer disease?
``` Acute coronary syndrome Gastrooesophageal reflux Gallstone disease Gastric malignancy Pancreatitis ```
189
What are the complications of peptic ulcer disease?
Perforation Haemorrhage Pyloric stenosis Anaemia
190
What are the risk factors for GORD?
``` Age Obesity Male Alcohol Smoking Caffeinated drinks Fatty or spicy foods Family history ```
191
What are the clinical features of GORD?
Dyspepsia Heartburn Burning retrosternal pain made worse after meals, lying down, bending over or straining Chronic cough or nocturnal cough Waterbrash Recurrent laryngitis, sore throat, asthma
192
What are the red flags for GORD?
``` Dysphagia Weight loss Early satiety Malaise Loss of appetite Vomiting Iron deficient Mass ```
193
What are the differential diagnoses of GORD?
Malignancy Peptic ulceration Oesophageal motility disorders Oesophagitis
194
What treatment can be given for GORD?
PPI H2 antagonist e.g. ranitidine Alginates e.g. gaviscon
195
What are the complications of GORD?
Barrett's oesophagus Aspiration pneumonia Oesophagitis and oesophageal stricture Oesophageal cancer
196
What is achalasia?
Oesophageal dysmotility syndrome Decreased peristalsis increased lower oesophageal sphincter tone Progressive problem with swallowing solids and liquids
197
What is the treatment for achalasia?
Calcium channel blockers Dilatation at OGD POEM NOTES
198
What can cause a benign oesophageal stricture?
``` GORD Oesophagitis Hiatus hernia Corrosives Surgical anastomosis ```
199
How can you treat a benign oesophageal stricture?
Dilatation - mechanical or balloon | Acid suppressive therapy e.g. PPI
200
What are the types of oesophageal cancer?
Squamous cell carcinoma | Adenocarcinoma
201
What are the clinical features of oesophageal cancer?
``` Dysphagia Feeling of lump in throat not associated with eating Regurgitation Weight loss Odonyphagia or hoarseness ```
202
What are the differential diagnoses of oesophageal cancer?
Benign oesophageal stricture Barrett's oesophagus Achalasia
203
How can you manage oesophageal cancer?
Oesophagectomy If squamous: chemo-radiotherapy + surgery if adenocarcinoma: chemo-radiotherapy + oesophageal resection Palliative - oesophageal stent, radio & chemotherapy, photodynamic therapy, RIG Analgesics and nutritional support
204
What is Barrett's oesophagus?
Intestinalisation of distal oesophageal non-keratinising stratified squamous epithelium
205
How do you manage Barrett's oesophagus?
PPI and surveillance HALO (radiofrequency ablation) EMR / ESD
206
What can cause an upper GI bleed?
``` Peptic ulcer bleed - duodenal or gastric Oesophageal varices Mallory-Weiss tear Oesophagitis / gastritis UGI malignancy Vascular lesions Clotting disorders Dieulafoy lesion Drugs ```
207
What are the clinical features of an upper GI bleed?
``` Haematemesis Melaena Abdominal discomfort Dizziness and SOB Tachycardia, hypotension, tender abdomen ```
208
When is a Sengstaken Blakemore tube indicated?
Unstable patients with massive variceal bleeding if: - endoscopy isn't available - endoscopy doesn't control the bleeding
209
What are the contraindications of a Sengstaken Blakemore tube?
History of oesophageal stricture | Recent oesophageal or gastric surgery
210
What are the complications of a Sengstaken Blakemore tube?
``` Airway obstruction Oesophageal rupture Aspiration pneumonitis Pain Ulcer of lipids, mouth, tongue Oesophageal and gastric mucosal erosions ```
211
What are the pre-hepatic causes of jaundice?
Excessive RBC breakdown causing unconjugated hyperbilirubinaemia Haemolytic syndrome Gilbert's syndrome Criggler-Najjar syndrome
212
What are the hepatocellular / intrahepatic causes of jaundice?
``` Alcoholic liver disease Viral hepatitis Iatrogenic - erythromycin, isoniazid, phenytoin, valproate, COCP Hereditary haematochromatosis Autoimmune hepatitis Primary biliary / sclerosing cholangitis Hepatocellular carcinoma ```
213
What are the post-hepatic causes of jaundice?
Obstruction of biliary damage Intraluminal causes e.g. gallstones Mural causes - cholangiocarcinoma, strictures, drug-induced cholestasis Extra-mural causes - pancreatic cancer, abdominal masses
214
What is the pattern of LFTs for an obstructive jaundice?
High bilirubin High ALP Normal ALT
215
What is the pattern of LFTs for a hepatocellular jaundice?
Very high ALT Varying bilirubin Raised ALP Increased PT
216
What is included in a liver screen of jaundice?
Acute liver injury - viral serology - hep A, B, C, E, CMV, EBV - non infective markers e.g. paracetamol level, caeruloplasmin, ANA antibody, IgG Chronic liver injury - viral serology - hep B, C - non infective markers - caeruloplasmin, ferritin and transferrin saturation, tissue transglutaminase antibody, alpha 1 antitrypsin, autoantibodies
217
What are the risk factors for a gastric cancer?
``` Male H.pylori infection Increasing age Smoking Alcohol consumption High salt intake Family history Pernicious anaemia Gastric polyps, FAP ```
218
What are the symptoms of gastric cancer?
``` Vague Dyspepsia Dysphagia Early satiety Melaena Vomiting Anorexia, weight loss, anaemia ```
219
What are the 2 types of bile salts and what are they made of?
Primary - cholic + chenodeoxycholic acid | Secondary - deoxycholic + lithocholic acid
220
Why do gallstones occur?
Too much absorption of water from bile Too much absorption of bile acids from bile Too much cholesterol in bile Inflammation of epithelium
221
What are the 3 types of gallstones?
Cholesterol Pigment stones Mixed stones
222
What are the 2 types of pigment gallstones and what are they associated with?
Black - associated with haemolytic disease | Brown - associated with chronic cholangitis and biliary parasites
223
What are the risk factors for gallstones?
``` Fat Female Fertile Forty Family history Haemolytic anaemia Malabsorption ```
224
What are the symptoms of biliary colic?
Sudden dull and colicky pain in RUQ Pain can radiate to epigastrium, back or right shoulder Precipitated by consumption of fatty foods Nausea and vomiting
225
What are the differential diagnoses of gallstone disease?
GORD Peptic ulcer disease Acute pancreatitis
226
What are the complications of gallstone disease?
``` Mucocele Mirizzi syndrome Gallbladder empyema Ascending cholangitis Chronic cholecystitis Perforated gallbladder Bouveret's syndrome and gallstone ileum Choledocholithiasis Pancreatitis ```
227
Why does conjugated bilirubin cause dark urine?
It is water soluble
228
What can cause a low albumin and low protein?
Advanced cirrhosis Alcoholism Protein malnutrition Chronic inflammation
229
What can cause a raised ALP?
Biliary obstruction Bone disease Pregnancy Certain malignancies
230
Why does blockage of a common bile duct prevent clotting factors being produced?
Vitamin K is fat soluble | Blockage of a common bile duct prevents fat absorption so stops vitamin K absorption
231
What are some non hepatic causes of deranged LFTs?
``` Drugs Right heart failure Sepsis Coeliac disease Haemolysis Hyperthyroidism Lower lobe pneumonia ```
232
What conditions are anti-smooth muscle autoantibodies found in?
Autoimmune hepatitis type 1
233
What conditions are anti-mitochondrial autoantibodies found in?
Primary biliary cholangitis
234
What conditions are anti-nuclear autoantibodies found in?
Autoimmune hepatitis type 1 | SLE
235
What drugs can cause deranged LFTs?
``` TB antibiotics Sodium valproate Methotrexate Methyldopa Amiodarone Statins Paracetamol Phenytoin Fluconazole Nitrofurantoin Sulfonylureas ```
236
What are the 3 consequences of cirrhosis?
``` Reduced metabolic capacity - coagulopathy - reduced albumin - hypoglycaemia Portal hypertension - ascites - hypersplenism - varices - hepatic encephalopathy Impaired immunity ```
237
What can cause cirrhosis?
``` Non-alcoholic fatty liver Alcohol Drug induced Viral hepatitis Biliary disease Autoimmune ```
238
What are the consequences of portal hypertension (SAVE)?
``` Splenomegaly Ascites Varices Encephalopathy Hepatorenal syndrome ```
239
What is the definition of diarrhoea?
Abnormal passage of loose or liquid stools at least 3 times a day and or a volume of stool greater than 200g/day
240
What drugs can cause diarrhoea?
``` Antibiotics Cytotoxics Laxatives PPI Digoxin NSAIDs Propranolol ```
241
What are the causes of acute diarrhoea?
Viral - norovirus, rotavirus, enteric adenovirus Bacterial - salmonella, campylobacter, shigella, S.aureus Parasitic - cryptosporidium parum
242
What are the causes of chronic diarrhoea?
Colonic - IBD, microscopic colitis, colorectal cancer Small bowel - coeliac, crown's, bile salt malabsorption, lactose intolerance, small bowel bacterial overgrowth Pancreatic - pancreatitis, pancreatic cancer, fibrosis Endocrine - hyperthyroidism, diabetes, Addison's disease, hormone secreting tumous Drugs, alcohol, factitious
243
What are the mechanisms of diarrhoea?
``` Osmotic Malabsorption Secretory e.g. E.coli Inflammatory e.g. Crohn's, UC Neoplastic Ischaemic Post-irradiation ```
244
What is the child-pugh scoring system used for?
Assess prognosis of chronic liver disease and cirrhosis
245
What does a bioavailability of 20% mean?
An oral dose of 100mg would be an equivalent exposure to an IV dose of 20mg
246
What is the consequence of cholestasis on drug handling?
Decreased absorption Lipid soluble medicines may be reliant on the action of bile salts to aid their absorption Drugs may be less well absorbed so there will be lower plasma concentrations and reduced efficacy e.g. with digoxin
247
What is the effect of ascites on pharmacokinetics and what drugs is this likely to affect?
Increases distribution | Water soluble medicines may distribute into ascetic fluid decreasing concentrations e.g. gentamicin
248
What is the effect of low albumin on pharmacokinetics and what drugs is this likely to affect?
Decreased distribution Affects highly protein bound drugs Increased free concentrations e.g. phenytoin
249
What is the effect of a high bilirubin on pharmacokinetics and what drugs is this likely to affect?
Decreased distribution Highly protein bound medicines will be effected. Bilirubin displaces highly bound protein drugs from their binding sites increasing the free concentrations of these drugs e.g. phenytoin
250
What are the 3 types of reactions in phase 1 drug metabolism?
Hydrolysis Oxidation Reduction
251
What is the difference between Crohn's and UC?
Crohn's affects entire tract, UC only affects colon UC inflammation is continuous and mucosal, Crohn's has skip lesions and is deep / transmural Blood is more common in UC Nausea and vomiting is more common in Crohn's Abdo pain is severe and continuous in Crohn's but is intermittent in UC Smoking worsens Crohn's but reduces UC symptoms Surgery is more effective for UC
252
What are the signs of an IBD flare up?
``` Bloody diarrhoea Nocturnal symptoms Urgency Mucous Changes in bloods ```
253
What 5 factors are included in the Harvey Bradshaw index for Crohn's disease activity?
1) General well being 2) Abdominal pain severity 3) Number of liquid stools per day 4) Abdominal pass 5) Complications - joint pain, uveitis, erythema nodosum, mouth ulcers, skin ulcers, anal fissure, new fistula, abscess, fever without infectious cause
254
What 6 factors are included in the simple clinical colitis activity index for UC disease activity
1) General wellbeing 2) Bowel frequency in day 3) Bowel frequency in night 4) Urgency of defecation 5) Blood in stool 6) Complications
255
What is the mechanism of 5-ASA?
Acts locally on colonic mucosa | Reduces inflammation
256
What are the side effects of 5-ASA?
``` Arthralgia Cough Diarrhoea Dizziness Fever GI discomfort Headache Leucopenia Nausea and vomiting Skin reactions ```
257
What is the mechanism of thiopurines?
Intracellular purine analogue and alkylation Decreased nucleic acid synthesis DNA damage
258
What are the contraindications of thiopurines?
Hypersensitivity Active infection Bone marrow impairment Live vaccines
259
What are the side effects of thiopurines?
``` Dizziness Flu like symptoms Nausea and vomiting Myelosuppression Pancreatitis Sun toxicity ```
260
What are the 1st line biologics for Crohn's?
Infliximab | Adalimumab
261
What are the 1st line biologics for UC?
Infliximab | Adalimumab
262
What is grade 1 ascites?
Mild ascites detectable only by USS
263
What is grade 2 ascites?
Moderate ascites manifested by moderate symmetrical distension of abdomen
264
What is grade 3 ascites?
Large or gross ascites with marked abdominal distension
265
What are the causes of ascites?
Hypoalbuminae - nephrotic syndrome, malnutrition Activation of RAAS Portal hypertension - cirrhosis, alcoholic hepatitis, acute liver failure, hepatic vena-occlusive disease, HF, constrictive pericarditis Peritoneal disease - malignant ascites, infectious peritonitis, peritoneal dialysis
266
What are the clinical features of ascites?
``` Distended abdomen with central resonance and dullness in flanks Painless Weight gain SOB Early satiety Shifting dullness Signs of liver disease ```
267
What does an ascitic tap that is clear / straw coloured indicate?
Liver cirrhosis
268
What does an ascitic tap that is cloudy indicate?
Spontaneous bacterial peritonitis, perforated bowel, pancreatitis
269
What does an ascitic tap that is bloody indicate?
Malignancy Haemorrhage Pancreatitis
270
What does an ascitic tap that is chylous indicate?
Lymphoma TB Malignancy
271
What can cause a low serum ascites-albumin gradient?
``` Malignancy Infection - TB Pancreatitis Nephrotic syndrome Hepatic vein thrombosis Budd-Chiari syndrome Hypothyroidism ```
272
What can cause a high serum ascites-albumin gradient?
``` Cirrhosis Hepatic failure Venous occlusion Fulminant hepatic failure Alcoholic hepatits Hepatocellular carcinoma Right ventricular failure Constrictive pericarditis Meig's syndrome ```
273
How can ascites be managed?
``` Avoid alcohol, low salt diet Spironolactone Add in furosemide as adjunct Therapeutic paracentesis Transjugular intrahepatic portosystemic shunt ```
274
What are the clinical features of autoimmune hepatitis?
Fatigue, arthralgia, anorexia, nausea Bruising, rashes Pruritus Signs of chronic liver disease - spider nave, palmar erythema, hepatomegaly / splenomegaly, oedema
275
How is autoimmune hepatitis treated?
High dose corticosteroid Azathioprine Transplant
276
What are the signs of cirrhosis?
``` Leukonychia Clubbing Palmar erythema Spider naevi Dupuytren's contracture Xanthelasma Gynaecomastia Loss of body hair Hepatomegaly ```
277
What can cause liver failure?
``` Infections Drugs - paracetamol overdose, isoniazid Toxins - carbon tetrachloride Veno-occlusive disease Alcohol Fatty liver disease Primary biliary / sclerosing cholangitis Haematochromatosis Autoimmune hepatitis Alpha1 antitrypsin deficiency Wilson's disease Malignancy ```
278
What are the causes of iron deficiency anaemia?
Malabsorption - dietary, coeliac, post gastrectomy, drugs e.g. PPI, tetracyclines Blood loss - NSAIDs, anticoagulants, peptic ulcer disease, menorrhagia, malignancy, frequent blood donation, haemorrhoids, oesophageal varices Increased physiological requirements - pregnancy, infancy
279
What are the clinical features of iron deficiency anaemia?
``` Tiredness or fatigue Headache Muscle aches SOB Palpitations Angina Intermittent claudication Hair loss Pallor Tachycardia Systolic murmur Angular stomatitis and glossitis Brittle nails and koilonychia ```
280
What would the FBC and iron studies show for an iron deficient anaemia?
Low MCV, MCHC and haemoglobin | Low Fe, low ferritin
281
What are the differentials of iron deficiency anaemia?
Thalassaemia Anaemia of chronic disease Sideroblastic anaemia Lead poisoning
282
What are the causes of GI malabsorption?
``` Coeliac disease Chronic pancreatitis Crohn's disease Decreasing bile - primary biliary cholangitis, ileal resection, biliary obstruction Pancreatic insufficiency - pancreatic cancer, CF Small bowel mucosa Bacterial overgrowth Infection Intestinal hurry ```
283
What are the clinical features of malabsorption?
``` Diarrhoea Weight loss Lethargy Steatorrhoea Bloating Anaemia, bleeding disorders, oedema, metabolic bone disease, neurological features ```
284
What are the clinical features of coeliac disease?
``` Steatorrhoea, diarrhoea Abdo pain Bloating Nausea and vomiting Aphthous ulcers Angular stomatitis Weight loss, fatigue, weakness Osteomalacia ```
285
What would the bloods show in coeliac disease?
Low Hb Low B12, low ferritin Anti-transglutaminase

KT (6 decks)

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