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MBBS VI - SpC - Family Medicine > GI: Viral Gastroenteritis, GERD, Constipation, Rectal bleeding, Functional dyspepsia, dLFT, Diarrhea > Flashcards

GI: Viral Gastroenteritis, GERD, Constipation, Rectal bleeding, Functional dyspepsia, dLFT, Diarrhea Flashcards

1
Q

Viral GE

Microbiology

A
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2
Q

Viral GE

Clinical presentation

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3
Q

Viral GE

Red flag S/S

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4
Q

Viral GE

Dehydration S/S

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5
Q

Viral GE

Management

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6
Q

Viral GE

ORS preparation
Common prescription

A

Loperamide
* Indicated in patients with absent of fever and stools are not bloody
* Avoid in patients with dysentery in fear of prolonging disease in such infection
* Anti-motility agent (Opioid receptor agonist)

Antibiotics
* Do NOT routinely recommend empiric antibiotics in patients with acute diarrhea
Indications
o Severe disease with fever, diarrhea > 6/day, volume depletion
o Invasive bacterial infection suggested by bloody or mucoid stools
o Prolonged disease refractory to treatment
o Host factors that increases risk for complications including age > 70 and
comorbidities such as immunocompromise conditions and cardiac disease

Antibiotic choice
o Fluoroquinolones: Ciprofloxacin/ Levofloxacin
o Macrolides: Azithromycin/ Erythromycin

Dietary recommendations
* Avoidance of food with high fat content
* Avoidance of dairy products

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7
Q

Diarrhea

Differentiate acute vs chronic, small vs large bowel, organic vs functional

A
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8
Q

Infective diarrhea

Microbiology

A
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9
Q

Non-infective diarrhea

Causes

A
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10
Q

Diarrhea

Key questions

A
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11
Q

Diarrhea

P/E

A
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12
Q

Diarrhea

Biochemical tests

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13
Q

Diarrhea

Radiological Ix

A
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14
Q

GERD

Definition
Pathological vs physiological reflux?

A
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15
Q

GERD

Classification

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16
Q

GERD

Risk factors

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17
Q

GERD

Pathophysiology

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18
Q

GERD

Clinical presentation

A

Red flags: Dysphagia/ Odynophagia/ Hematemesis/ Melena/ Anemia/ Vomiting/ Weight loss/ Family history of esophageal or gastric cancer/ Chronic NSAIDs usage

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19
Q

GERD

Ddx

A
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20
Q

GERD

Biochemical test

A

Approach to NCCP:
1. Clinical diagnosis by Hx & P/E (esp. Cardiovascular exam), Validated Chinese GERD Questionnaire (7 questions)
2. PPI at standard dose b.d. for 4-8w
3. If failed, 24h Oesophageal pH Monitoring
4. If failed (-ve result), Manometry for Oesophageal motility disorder

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21
Q

GERD

Radiological Ix

A
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22
Q

GERD

Lifestyle modification and advice

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23
Q

GERD

Medical treatment

A

-Regimen Now: Step-down regimen (from PPI)
* Quick symptom control & oesophagitis healing
* Confirm diagnosis
* Low drug & consultation cost

Drug given lifelong/ intermittently/ on demand

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24
Q

GERD

Surgical treatment

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25
Q

GERD

Common prescriptions

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26
Q

Deranged liver function test

Components of liver function test

A
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27
Q

dLFT

Patterns of deranged LFT

A
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28
Q

ALT AST

Refernce range
Location

A
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29
Q

ALT AST

Ratio significance

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30
Q

dLFT

Ddx marked vs mild elecation

A
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31
Q

dLFT

Cholestatic pattern ddx

A
32
Q

ALP GGT

ddx mild vs marked elevation

A
33
Q

Evaluation of elevated ALP

A
34
Q

Common drugs causing dLFT

A
35
Q

IBS

Pathophysiology

A
36
Q

IBS

Subtypes

A
37
Q

b

IBS

Clinical presentation

A
38
Q

IBS

Diagnosis

A
39
Q

IBS

Ix

A
40
Q

IBS

Management

A
41
Q

Constipation

Causes

A
42
Q

Constipation

Clinical presentation

A
43
Q

Constipation

Complications

A
44
Q

Constipation

P/E

A
45
Q

Constipation

Ix

A

Assessment of complications to decide on operative vs non-operative Mx
□ CBC, L/RFT: infection, anaemia, dehydration
□ ABG + lactate: acidosis (ischaemia), alkalosis (vomiting)
□ Amylase to r/o acute pancreatitis
□ Erect CXR + E/S AXR for perforation and strangulation

Radiographic Ix:
Erect/supine AXR
Contrast CT abdomen
Water soluble contrast study by gastrografin (GGF)
Lower endoscopy

46
Q

Constipation

Management

A

Common prescriptions for Constipation
- Bulk Laxatives: Methylcellulose 500mg tablets PO 3-6 tablets b.d.
- Osmotic Laxatives: Lactulose 680mg/ml solution PO 15ml b.d.
- Stimulant Laxatives: Bisacodyl 5-10mg tablet q.d., taken at night

47
Q

Dyspepsia

Definition
Red flag S/S

A
48
Q

Dyspepsia

Causes

A
49
Q

Dyspepsia

Pathogenesis

A
50
Q

Dyspepsia

Key questions

A
51
Q

Dyspepsia

P/E

A
52
Q

Dyspepsia

Ix

A

Functional dyspepsia diagnosed by exclusion after investigations

53
Q

Dyspepsia

Treatment

A
54
Q

Rectal bleeding/ LGIB

Causes

A

Diverticular bleeding (15 – 55%) (most common)
* Bleeding is usually painless with mild abdominal discomfort and cramping due to colonic spasm from intraluminal blood
* Risk factors include advanced age, obesity, hypertension, hyperlipidemia, IHD, chronic renal insufficiency and use of aspirin or NSAIDs

Angiodysplasia (most common in age > 65)
* Acquired conditions associated with degeneration of vascular walls from aging

Hemorrhoids (most common in age < 50)
* Usually asymptomatic but can present with painless hematochezia, thrombosis, strangulation or pruritus

Colitis
* Infectious/ Ischemic/ Radiation colitis

Inflammatory bowel disease

Colorectal Cancer

Anorectal diseases: rectal ulcers, rectal varices, anal ulcers, anal fissures and Dieulafoy’s lesions

Following biopsy or polypectomy

Radiation telangiectasia and proctitis

Massive bleeding from small bowel sources
* Meckel’s diverticulitis
* Crohn’s disease
* Angiodysplasia
* Hemangioma

55
Q

Rectal bleeding/ LGIB

Key questions

A
56
Q

Rectal bleeding/ LGIB

P/E

A
57
Q

Rectal bleeding/ LGIB

Biochemical Ix

A
58
Q

Rectal bleeding/ LGIB

Radiological Ix

A

Proctoscopy (first-line)

Colonoscopy
OGD
CT angiography/ IV angiography

59
Q

Common S/S of anorectal diseases

A

Bleeding (fresh)
Anal pain
Discharge (bloody or purulent)
Prolapse
Peranal mass
Pruritis ani
Incontinence

60
Q

Investigations for anorectal diseases

Imaging
Physiological tests

A

P/E:
General exam
Abdominal exam
Perianal exam
Digital rectal exam
Proctoscopy

Imaging:

Rigid sigmoidoscopy
Flexible endoscopy
Transrectal ultrasound
MRI: complicated abscesses/ fistulas
Others (old, superceded): Defecography, Fistulogram
Physiological: constipation and incontinence

Anorectal manometry
Electromyogram
Pudendal nerve latency test

61
Q

Hemorrhoids

Risk factors
Degrees

A

Risk factors:
 Low fibre diet
 Family history of hemorrhoids
Increased intra-abdominal pressure
 Pregnancy
 Constipation, straining
 Chronic cough
 Obesity

Four degrees of internal hemorrhoids
 1st degree: Bleeding only without prolapse
 2nd degree: Prolapse at defecation but reduce spontaneously afterwards
 3rd degree: Prolapse and have to be manually reduced
 4th degree: Permanently prolapsed, Cannot reduce

62
Q

Hemorrhoids

Clinical presentation

A

 Irritation or pruritus
 Bright-red painless bleeding (ALWAYS exclude other possible sources of PR bleeding)
 Mucous discharge
 Prolapsed mass
 Pain (from complications like thrombosis, prolapse)

63
Q

Hemorrhoids

Management

A

Conservative:
Diet modification: High fiber diet

Sitz bath: relax sphincter muscles and reduce spasm, pruritis, inflammation
For significant haemorrhoids with prolapse

Ointment and suppositories

  • Analgesic cream: mixed lidocaine/ hydrocortisone
  • Hydrocortisone suppositories: shrink hemorrhoids
  • Venoactive agents: Phlebotonics e.g. Daflon to control bleeding

Laxatives/ Stool softeners
* Osmotic laxative e.g. Lactulose
* Bulk laxative e.g. Methycellulose
* Stimulant laxative e.g. Senna/ Bisacodyl

Office procedures:
* Rubber band ligation
* Sclerotherapy
* Infra-red coagulation

In-patient surgeries:
* Surgical hemorrhoidectomy
* Stapled haemorrhoidopexy
* Transanal hemorrhoidal artery devascularization

64
Q

Complications of untreated hemorrhoids

A

Complications of hemorrhoids
 Strangulation and thrombosis
 Gangrene
 Ulceration
 Fibrosis
 Portal pyemia

65
Q

Anal fissures

Causes

A
  1. Primary causes
    Local trauma to anal canal
    * Passage of hard stools
    * Prolonged diarrhea
    * Vaginal delivery
    * Anal sex
    Secondary causes
    Inflammatory bowel disease
    * Crohn’s disease
    * Ulcerative colitis
    Granulomatous disease
    * Extrapulmonary TB
    * Sarcoidosis

Malignancy
* Squamous cell anal cancer
* Leukemia

Sexually-transmitted diseases
* HIV infection
* Syphilis
* Chlamydia

66
Q

Fissure-in-ano

S/S
Typical and atypical features

A

Signs and symptoms:
1. Painful defecation
* Tearing pain with passage of bowel movements
2. Bright rectal bleeding
* Limited to a small amount on toilet paper or surface of stool
3. Perianal pruritus or skin irritation

Typical features:
* Single posterior or anterior fissure without evidence of Crohn’s disease

Atypical features
* Multiple, recurring, non-healing, deep or wide, painless and at off-midline locations
* Suggests secondary causes of anal fissures

67
Q

Physical examination technique for anorectal fissure

How to differentiate acute from chronic fissure

A

Most common location of primary anal fissure is posterior anal midline
Spread buttock to reveal fissure, DO NOT PERFORM RECTAL EXAM OR PROCTOSCOPY

Acute fissure (Pathognomonic feature = Superficial tear)
o Superficial tear
o Fresh laceration resembling a paper cut

Chronic fissure (Pathognomonic feature = Hypertrophied with skin tags or papillae)
o Raised edges exposing white horizontally oriented fibers of the internal anal sphincter muscle fibers at the base of fissure
o Hypertrophied anal papillae at the proximal end of fissure
o Skin tags (sentinel pile) at the distal end of fissure

68
Q

Surgical treatment options for fissure-in-ano

A

Indicated in patients who fail 8 weeks of initial medical treatment
 Botulinum toxin type A injection
 Lateral internal sphincterotomy

69
Q

Anorectal abscess

Etiologies

A

Cryptoglandular infection
* Infection of the anal glands

Other infections
* Inflammatory bowel disease
* Tuberculosis
* Actinomycosis
* Foreign body
- Surgical
Malignancies

70
Q

Anorectal abscess

Pathogenesis

S/S

Treatment

A

Pathogenesis of an anal abscess
 Originates from an infected anal crypt gland which penetrate the internal sphincter and end in the intersphincteric plane
 Obstruction of anal crypt gland with inspissated debris permits bacterial growth and abscess formation

Signs and symptoms
Pain in anal or rectal area
* Constant pain
* Not necessarily associated with a bowel movement
* Associated with symptoms including fever and malaise
Purulent discharge
Constipation
Urinary difficulties
Tx:
Incision and drainage
Antibiotics has MINIMAL role
* Except in patients with cellulitis, valvular heart disease, prosthetic heart valves and immunosuppression

71
Q

Causes/ etiologies of anorectal fistula

Ddx

A

Anorectal abscesses (most common >90%)
* Often evolves from a spontaneously draining anorectal abscess originating from the crypts of Morgagni (cryptoglandular infection) which are located between two layers of anal sphincter
Other causes:
Crohn’s disease, Lymphogranuloma venereum (Chlamydia trachomatis), Radiation proctitis, Rectal foreign bodies, Actinomycosis

Ddx:
 Anal abscess
 Anal fissure
 Anal ulcers or sores

72
Q

Anorectal fistula

S/S

A

Painful defecation
* Intermittent rectal pain particularly during defecation but also with sitting and activity

Bleeding

Swelling

Purulent drainage - lowers pain
* Intermittent and malodorous perianal drainage

Perianal pruritus

73
Q

Anorectal fistula

Investigations
Indication for imaging

A

Internal and external opening of fistula tract need to be identified

 Anorectal examination
 Anoscopy or sigmoidoscopy

Radiological tests
 Examination under anesthesia (EUA) with Fistula Probe

Imaging modalities:
* Endosonography (EUS)
* CT/ MRI anal canal
* Fistulography

MRI for: complicated high fistula, recurrent fistula, poor anatomy

74
Q

Anorectal fistula

Surgical treatment options
Alternative/ advanced treatment options

A

Simple low fistula - Fistulotomy/ Fistulectomy

Complicated high fistula/ transphincteric fistula with muscle involvement:

Setons: Cutting (snug) seton, Draining seton
Endorectal advancement flap: Closing off the internal opening of fistula by a mobilized flap
Anal fistula plug: ameliorate postoperative incontinence
Ligation of intersphincteric fistula tract (LIFT): Secure closure of internal opening and removal of infected cryptoglandular tissues
Others:
Video-assisted anal fistula treatment (VAAFT)
- FiLaC (Fistula tract laser closure)
- Permacol paste injection
- Stem cell treatment

75
Q

Rectal prolapse

Definition
Cause
Differentiate complete and partial prolapse

A

Rectal prolapse is a pelvic floor disorder. Full thickness protrusion of rectum through anal sphincters

Failure of pelvic floor muscles/ levator ani (puborectalis + pubococcygeus + iliococcygeus muscles)

Extent of rectal prolapse
* Complete rectal prolapse refers to protrusion of all layers of rectum through the anus
* Partial rectal prolapse refers to protrusion of the mucosa only

76
Q

Rectal prolapse

Etiologies

A

Neurological disorders: Dementia, Stroke

Parity, female, age>40, vaginal delivery

Chronic Constipation/ straining/ diarrhea

Childhood factors: Cystic fibrosis, Whooping cough, Developmental abnormalities, Malnutrition

77
Q

Rectal prolapse

Treatment options for abdominal and perineal repair

A

Abdominal repair:
Rectal fixation (suture/ mesh)
Sigmoid resection
Proctectomy
Combination rectal fixation and sigmoid resection
Laparoscopic Ventral Mesh Rectopexy

Perineal repair:
Full thickness resection
Mucosal resection with muscular reefing
Anal encirclement

MBBS VI - SpC - Family Medicine (42 decks)

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