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
