GIT and hepatology Flashcards
what are the symptoms of appendicitis?
RHS lower quadrant pain from periumbilical site (T8 - T10)
anorexia
N/V
some other atypical features such as: diarrhea, bowel irregularity, flatulence, indigestion
what are the signs of appendicitis?
mcburney’s point tenderness; maximal tenderness 2/3 from umbilical to ASIS
Rosving’s (cross tenderness) sign
psoas sign - pain on active flexion of hip or passive extension of hip
sign of peritonism: tenderness, guarding, rebound tenderness, percussion tenderness
investigations and diagnosis of appendicitis
clinical diagnosis based on clinical history and examination of:
- anorexia
- nausea vomiting
- migratory RHS iliac fossa pain
- tenderness in RLQ
- rebound tenderness RLQ
- fever > 37.5
- leukocytosis
management of appendicitis
acute treatment: DRABC IV access --> IV fluid analgesia anti-emetic, NBM prophylatc abx: ceftriaxone + metronidazole
laparoscopic appendectectomy (gold standard)
classic features of cholecystitis
prolonged (4 - 6 hours) that is steady, severe. made worse by fatty food can radiate to RHS shoulder or back fever, chills, rigors nausea/vomiting, anorexia signs: positive murphy's sign no signs of jaundice
management of cholecystitis
acute mx: DRABC, IV hydration, correction of e- imbalance, pain control and opioid, antibiotics:
- less than 72h: amoxicillin/ampicillin + gentamicin
- more than 72h: ceftriaxone or tazocin
- if presence of obstructive symptoms: metronidazole
surgery if patient sx are severe and development of complications
what is rigler’s triad and what is it associated with?
SBO, pneumobilia, ectopic gallstones on AXR/US/CT
gallstone ileus
what are the risk factors for cholecystitis?
female obesity pregnancy drugs (increased HRT) increased age
what is the next investigation to do in a suspected cholecystitis?
U/S - presence of gallstones, gall bladder wall thickening > 4 - 5 mm or edema, pericholecystic fat inflammation or fluid
what are the features of uncomplicated gall bladder disease?
constant, intense dull discomfort located in the RUQ
pain lasts about 30 - 60 mins, and self resolves with entire episode less than 6 hours
+n/v and diaphoresis
what are the management of uncomplicated gall bladder disease?
if asymptomatic, no treatment
if symptomatic and classical tx: analgesia w/ NSAIDs or opioids, and prophylactic tx to remove offending stones
if asymptomatic and atypical sx: empirical UDCA (urosdeoxycholic acid) treat symptomatically
if symptomatic and no gall stone on U/S: HIDA scan
what are the features of choledocholithiasis?
can present w/ typical biliary colic + pain is usually more prolonged
jaundiced
RUQ or epigastric tenderness
what are the features of acute cholangitis?
charcot’s triad: RUQ pain, fever, jaundice
if more serious there will be reynold’s pentad: hypotension and altered mental status
what are the investigations for acute cholangitis?
if it is high risk, ERCP to confirm diagnosis and provide biliary drainage
if at intermediate risk, U/S to show common bile duct dilation or underlying cause. if no finding, ERCP within 24 hours, if U/S has no finding, do MRCP
supportive measure:
- analgesia, IV fluid, prophylactic abx (IV ceftriaxone + metronidazole if previous biliary tract surgery or known biliary obstruction)
what is the treatment of choledocholithiasis?
stratification into high/intermediate/low risk
high risk –> ERCP w/ stone removal, followed by cholecystectomy
intermediate risk –> preoperative endoscopy U/S or MRCP
what is the clinical feature of GORD?
acid brash in mouth
heartburn (retrosternal chest pain that feels like a burn)
post prandial
aggrevated on lying down
worse w/ alcohol
other extra-eosophageal manifestations: dental erosions, chronic cough
risk factors for GORD?
caucasian
obesity, pregnancy, chronic cough
drugs such as CCB, sedatives, anticholinergics, caffeine, smoking, alcohol
investigations and diagnosis for GORD
clinical diagnosis and clinical trial of PPI
if trial of PPI is refractory –> endoscopy + ambulatory pH monitoring
other investigations available are:
- endoscopy w/ mucosal biopsy –> done at presentation w/ oesophageal GORD syndrome w/ troublesome dysphagia (LOW, N/V, dysphagia, haemetemesis), new sx > 50 years old OR to evaluate clinically diagnosed GORD that is refractory to 2 weeks of PPI trial
- ambulatory pH monitoring –> current gold standard diagnosis of GORD
- manometry –> used to evaluate peristaltic function to diagnose/exclude major motor disorders
- double contrast barium swallow –> able to identify early stages of reflux oesophagitis, peptic strictures, shallow ulcers and erosions
what is the mx of GORD?
non pharm: avoid fatty/oily food decreased alcohol and smoking weight reduction avoid drugs that cause LES relaxation elevate head of the bed
pharm:
(first line) PPI, taken 30 minutes before dinner
(second line) Ranitidine
augments are:
antacids
prokinetic agents such as; domperidone, metoclopramide
what are the complications of GORD?
oesophageal strictures (symmetrical/circumferential narrowing of the involved oesophagus) that causes dysphagia to solids
oesophagitis that causes odynophagia
barrets oesophagus
what is the metaplastic change found in barret’s oesophagus?
metaplastic epithelium from stratified squamous to columnar epithelium
what are the pathological findings of a patient with barret’s oesophagus?
- macroscopically
- microscopically
macroscopic: salmon-tan, velvety mucosa between smooth, pearly oesophageal squamous epithelium
microscopic:
squamocolumnar munction must be more than 3cm above the gastroesophageal junction
oesophageal squamous epithelium is replaced by metaplastic columnar epithelium
what are the classifications of barret’s oesophagus?
non dysplastic (most common)
low grade dysplasia
high grade dysplasia
what is the management of barret’s oesophagus?
GORD therapy
regular surveillance therapy through endoscopy :
- no dysplasia = 1 - 2 years
- low grade dysplasia = every 6 months
Dx question:
dysphagia of both food and water w/ regurgitation of food
what is the dx, ix findings and mx?
dx: achalasia
ix: bird’s beak finding on barium swallow, mamotery will show lower 2/3 esophagus aperistalsis and incomplete LES relaxation
tx: nitrates/CCB OR dilatation of LES/surgical myotomy of the LES
dx question:
hx of heartburn, progressive dysphasia to both fluid and liquid, periodic sticking sensation at the back of the throat. there is also associated reynauld phenomenon, and thickening of the skin on the fingers
what is the dx, ix findings, and mx
dx: scleroderma esophageal dysmotility
ix: absence of peristaltic waves in the lower 2/3 of the esophagus w/ significant decrease in LES tone
CREST - calcinosis, raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia
dx question:
hx of spontaenous severe, non cardiac (retrosternal) chest pain due to uncoordinated contractions of the esophageal body
odynophagia on cold and warm water
intermittent dysphagia to food and water
what is the dx, ix findings and mx
ix: mamometry will show multiple contractions at high amplitude on tracing from the middle to lower esophagus
barium swallow will show a corkscrew pattern
tx: CCB and nitrates
dx question:
hx of GORD, dysphagia to food only
peptic strictures
dx question:
regurgitation of old food, causing it to stick to the back of the throat
zenkers diverticulum
dx question:
rapidly progressive dysphagia (From initially food to both food and water)
accompanied by constitutional sx such as LOW, LOA, fatigue, mild fever, anemia
oesophageal cancer
dx question:
young man/child w/ hx of asthma and allergic rhiniitis
dysphagia to solid food, accompanied w/ abdominal pain and vomiting
eosinophilic oesophagitis
ix: upper endoscopy w/ esophageal biopsies - finding of eosinophils in the squamous epithelium of the oesophagus
what is clinical features of IBS?
chronic crampy abdo pain relieved by defecation
altered bowel habits that can range from cyclical diarrhoea and diarrhea or just either
half of patients with IBS will complain of mucus discharge w/ stools
some other associated features are: early satiety, nausea, non cardiac chest pain, intermittent dyspepsia, abdominal bloating and increased gas production in the form of flatulence or belching
what are the investigations necessary for diagnosis of IBS?
IBS is a clinical diagnosis and a diagnosis of exclusion.
some of the investigations that should be done are:
celiac disease - tissue transglutimase antibody
FBE - anemia
CRP/ESR - systemic inflammation
thyroid function tests
breath hydrogen testing for fructose/lactose intolerance
bimanual pelvic examination and pelvic U/S to rule out cervical CA if there is pelvic pain in women
colonoscopy/PR examination
what is the management of IBS?
education and reassurance
dietary modification of diet and referral to dietician - dont eat FODMAP food, dont eat gas producing food, trial lactose free diet, eat more fibre
physical activity
psychological therapy
adjunctive pharmacotherapy to support sx such as:
constipation - movicol, coloxyl, lactulose
diarrhoea - loperamide, bile salt binders
abdominal pain and bloating - buscopan, anti depressants
what is the difference between the macroscopic appearance of a benign peptic ulcer vs a malignant ulcer
benign peptic ulcer: punched out appearance, smooth and regular and rounded margins, that is not elevated or beaded. flat smooth ulcer bases.
malignant peptic ulcer: ulcerating protruding mass, rolled edges that are elevated, necrotic ulcer base, irregular margins
what investigations and diagnosis of peptic ulcer disease?
gold standard diagnosis is upper endoscopy
other investigations that can be done are: urease breath test for H pylori infection
what is the treatment of uncomplicated PUD?
antisecretory therapy: PPI
h pylori therapy: CAP (clarithomycin, amoxicillin, PPI)
non pharm therapy:
cessation of smoking, alcohol
cessation of aggravating drugs such as NSAIDs
monitor progression and healing of ulcer, benign ulcers should heal in 8 - 12 weeks time
what is zollinger ellison syndrome and how is it diagnosed?
gastrinoma w/ hyper secretion of acid
gastrin levels of > 1000mg/dL are diagnostic. secretion stimulation test can show if gastrin level is not low.
what are the causes of duodenal ulcer vs gastric ulcer?
duodenal ulcer = close to 100% h pylori cause
peptic ulcer = 1/2 h pylori, 1/2 NSAIDS or alcohol
what is the treatment of complicated PUD?
acute mx:
DRABC
supportive therapy: fluids, e- balance, monitor BP, ECG, O2 supplement
cross and match
IV PPI
gastro consult and surgical consult for endoscopic treatment –> adrenaline injection/sclerotherapy
what are the features of autoimmune chronic gastritis and what are its associations?
associated with thyroiditis, T1DM, vitiligo, Addison’s, hypoparathyroidism
features are:
anemia (megaloblastic) - SOB, pallor, fatigue, angina
neurological - altered reflexes/sensory deficits, cognitive impairment
others - angular chelitis, atrophic glossitis
what is the treatment of pernicious anemia?
pernicious anemia is the destruction of parietal cells and the loss of intrinsic factor
IM cyanocobalmin
what are the features of celiac disease in the:
- adult
- child
adult: steatorrhea, weight loss, abdominal pain and distension, flatulence, malabsorption signs (pallor, bone pain, easy bruising, hyperkeratosis), dermatitis hepatiformis (pruritic papulovesicular blistering condition that is usually distributed on extensor surfaces)
child: failure to thrive, weight loss, fatigue, delayed puberty, short stature
celiac disease investigation algorithm and diagnosis
- serology: IgA anti tissue transglutaminase (TTG), IgA endomysial antibody
- HLA-DQ2/DQ8 halotyping for exclusion
- duodenal biopsy (gold standard) - subtotal villous atrophy, increased intraepithelial WBC and crypts
what are the vitamin deficiencies that can be found in malabsorption? What are their symptoms?
Vitamin D, A, K, E
Vitamin D - Bone pain, osteomalacia
Vitamin A - hyperkeratosis
Vitamin K - Easy bruising
subepidermal split w/ IgA deposition along the dermal papillae
dermatitis herpetiformis
what is the management of celiac disease
dietary modifcation - gluten free diet
monitoring response to gluten free diet w/ IgA TTG or IgG DGP
test for Vitamin DAKE deficiency and supplement accordingly
pneumococcal vaccination as hyposplenism is a potential complication of celiac disease (howell jolly body)
what are the risk factors diverticular diseases?
older aged caucasian low dietary fibre, high red meat drugs - aspirin and NSAID use, steroids, opiates obesity, physical inactivity
what are the typical features of diverticulitis?
fever, LLQ pain/tenderness that is constant, nausea/vomiting, changes in bowel habit (constipation, diarrhoea)
what is the acute treatment of diverticulitis?
DRABC
NBM, IV fluid
analgesia
anti-emetic
antibiotics:
- mild; amoxicillin/clauvanate + metronidazole
- severe: IV ampicillin + gent + metronidazole for 7 days. if no improvement within 72h, use CT scan to look for abscess
investigation and diagnosis of diverticulitis?
CT with oral and IV contrast (gold standard) = will show bowel wall thickening, pericolonic fat stranding, presence of colonic diverticula
NO colonoscopy due to perf risk, stnadard practice to do it after 6 weeks to rule out colorectal cancer
what is the clinical features of diverticular disease?
asymptomatic
painless rectal bleeding (bright red) that settles spontaneously in most patient
what are the non pharmacological recommendation for diverticular diseases?
increase diet fibre and reduce red meat
regular exercise
stop smoking
what are the classification of haemarrhoids?
grade 1: no prolapse
grade 2: prolapse out with defecation or with straining but reduce spontaneously
grade 3: prolapse out of anal canal with defecation or with straining but require manual reduction
grade 4: irreducible and may strangulate or thrombose
what the features of haemarrhoids?
pruritus
tenesmus
in external haemarrhoids, painful to touch and pressure
in internal haemarrhoids, discomfort without pain, mild fecal leakage/incontinence
what is the treatment of uncomplicated haemarrhoids?
dietary management: adequate fibre, and fluid intake
analgesic cream
warm baths
hydrocortisone suppositories for less than 1 week to avoid side effects
what is the treatment of refractory haemarrhoids or symptomatic third/forth degree haemarrhoids?
clinic procedural intervention: rubber band ligation, sclerotherapy
surgical intervention - hemarrhoidectomy
what are the investigations and diagnosis of haemarrhoids?
can be clinical diagnosed by PR examination
investigations that can be done are: colonoscopy (important if pt is > 40 w/ risk factors for CRC or IBD)
FBE may show microcytic anemia (fe deficiency anemia)
fecal occult blood test will be positive
what are the prodrome sx of hep a/b
non specific
