List I - Core Conditions Flashcards

Question

What is the prognosis of oesophageal cancer?

Answer 1

* 5 year survival rate is 15%

Answer 2

* Low third of oesophagus - near the gastro-oesophageal junction

Answer 3

* GORD * Barrett's oesophagus * Smoking * Achalasia * Obesity

Answer 4

* Upper two thirds of the oesophagus

Answer 5

* Smoking * Alcohol * Achalasia * Plummer-Vinson sydrome * Diets rich in nitrosamines

Answer 6

* Upper GI endoscopy is first line test * Staging is done with CT chest, abdomen and pelvis * If CT does not show metastatic disease, then local stage may be more accurately assessed by use of endoscopic USS * Staging laproscopy is performed to detect occult peritoneal disease * PET CT is performed in those with negative laparoscopy

Answer 7

* Surgical resection if possible * Most standard is the Ivor-Lewis type oesophagectomy: - Involves the mobilisation of the stomach and division of the oesophageal hiatus - Abdomen is closed and a right sided thoracotomy performed, stomach is brought to the chest and the oesophagus mobilised further - Intrathoracic oesophagogastric anastomosis is constructed - Alternative surgical strategies include a transhiatal resection (for distal lesions), a left thoracoabdominal resection (difficult access due to thoracic aorta) and a total oesophagectomy (McKeown) with a cervical oesophagogastric anastomosis * Biggest risk is an anastomotic leak, with an intrathoracic anastomosis this will result in mediastinitis - high mortality * McKeown technique has an intrinsically lower systemic insult in the event of anastomotic leakage * In addition to surgery, most patients are treated with adjuvant chemotherapy

Answer 8

* A hiatus hernia describes the herniation of part of the stomach above the diaphragm.

Answer 9

* Sliding (A) accounts for 95% of hiatus hernia, the gastrooesophageal junction moves above the diaphragm * Rolling (B) (paraoesophageal): the gastroesophageal junctions remains below the diaphragm but a separate part of the stomach herniates through the oesophageal hiatus

Answer 10

* OGD is gold standard

Answer 11

``` Weight loss Stop smoking Stop/reduce alcohol Lose weight PPI prescription ```

Answer 12

* Indicated when: - Remaining symptomatic despite conservative measures including medication - Increased risk of strangulation - Nutritional failure due to outlet obstruction

Answer 13

Types of surgery: - Cruroplasty – hernia is reduced from the thorax to the abdomen and the hiatus reapproximated to size – large defects require mesh to strengthen the repair - Fundoplication – gastric fundus is wrapped around the lower oesophagus and stitched in place – strengthens the lower oesophagus and keep the GOJ in place below the diaphragm

Answer 14

* Epigastric pain * Nausea * Gastric ulcers - Epigastric pain worsened by eating * Duodenal ulcers - More common than gastric ulcers - Epigastric pain when hungry, relieved by eating

Answer 15

* Helicobacter pylori is associated with the majority: - 95% of duodenal ulcers - 75% of gastric ulcers * Drugs - NSAIDs - SSRIs - Corticosteroids - Bisphosphonates * Zollinger-Ellison syndrome: rare cause characterised by excessive levels of gastrin, usually from gastrin secreting tumour

Answer 16

* Urease breath test or stool antigen test should be first line

Answer 17

* If negative - then PPI's should be given until the ulcer is healed * If positive for H. Pylori, then eradication therapy should be given

Answer 18

* 7 day course - PPI + amoxicillin + (clarithromycin or metronidazole) - If penicillin allergic: PPI + metronidazole + clarithromycin

Answer 19

* Acute bleeding | * Perforation

Answer 20

* Gastro-duodenal artery

Answer 21

* Haematemesis * Malaena * Hypotension * Tachycardia

Answer 22

* A to E assessment * IV PPI * Endoscopy is first line intervention * If this fails then most patients have: - Urgent interventional angiography with transarterial embolization or surgery

Answer 23

* Symptoms develop suddenly - Epigastric pain, later becoming more generalised - Patients may describe syncope

Answer 24

* Diagnosis is largely clinical * Plain film x-rays are the first form of imaging to obtain * Upright (erect) chest x-ray is usually required when a patient presents with acute upper abdominal pain * This is a useful test as approximately 75% of patients with a perforated peptic ulcer will have free air under the diaphragm 'pneumoperitoneum'

Answer 25

* 700,000 new cases of gastric cancer worldwide each year * Overall incidence is decreasing, but incidence of tumours arising from the cardia is increasing * Peak age = 70-80 years * More common in Japan, China, Finland and Colombia than the West * More common in males 2:1

Answer 26

* Signet ring cells may be seen in gastric cancer * They contain a large vacuole of mucin which displaces the nucleus to one side * Higher number of signet ring cells are associated with worse prognosis

Answer 27

* H. Pylori infection * Blood group A: gAstric cAncer * Gastric adenomatous polyps * Pernicious anaemia * Smoking * Diet: salty, spicy, nitrates * May be negatively associated with duodenal ulcer

Answer 28

* Dyspepsia * Nausea and vomiting * Anorexia and weight loss * Dysphagia

Answer 29

* Diagnosis: endoscopy with biopsy | * Staging: CT or endoscopic ultrasound - endoscopic USS has recently been shown to be superior to CT

Answer 30

* Type 1 - True oesophageal cancers and may be associated with Barrett's oesophagus * Type 2 - Carcinoma of the cardia, arising from the cardiac type epithelium or short segments with intestinal metaplasia at the oesophagogastric junction * Type 3 - Sub cardial cancers that spread across the junction. Involve similar nodal stations to gastric cancer

Answer 31

* Proximally sited disease greater than 5-10cm from the OG junction may be treated by sub total gastrectomy * Total gastrectomy if tumour is <5cm from OG junction * For type 2 junctional tumours (extending into the oesophagus) oesophagogastrectomy is usual * Endoscopic sub mucosal resection may play a role in early gastric cancer confined to the mucosa and perhaps the sub mucosa (this is debated) * Lyphadenectomy should be performed * A D2 lyphadenectomy is widely advocated by the Japanese, the survival advantages of extended lyphadenectomy have been debated, however overall recommendation is that D2 nodal dissection be undertaken * Most patients will receive chemotherapy either pre or post operatively

Answer 32

* Gastric MALT lymphoma

Answer 33

* H. Pylori infection in 95% of cases * Good prognosis * If low grade then 80% respond to H. pylori eradication

Answer 34

* Classically painless jaundice - Pale stools - Dark urine - Pruritis - Cholestatic liver function tests * Courvoisier's law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones * Patients typically present in non-specific way with anorexia, weight loss, epigastric pain * Loss of exocrine function e.g. steatorrhoea * Loss of endocrine function e.g. diabetes mellitus * Atypical back pain is often seen * Migratory thrombophlebitis Trousseau sign is more common than with other cancers

Answer 35

* USS - sensitivity 60-90% * High resolution CT scanning is the investigation of choice if the diagnosis is suspected * Imaging may demonstrate the double duct sign * Presence of simultaneous dilation of the common bile and pancreatic ducts

Answer 36

* Less than 20% are suitable for surgery at diagnosis * Whipple's resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of the pancreas * Side effects of the Whipple's include dumping syndrome and peptic ulcer disease * Adjuvant chemotherapy is usually given following surgery * ERCP is often used for palliation

Answer 37

* Autoimmune condition causing sensitivity to the protein gluten * Repeated exposure leads to villous atrophy which can in turn cause malabsorption

Answer 38

Signs and symptoms - Chronic or intermittent diarrhoea - Failure to thrive or faltering growth - Persistent unexplained GI symptoms including vomiting and nausea - Prolonged fatigue - Sudden unexpected weight loss - Unexplained iron deficiency anaeamia or other anaemia

Answer 39

* Anaemia – iron, folate, B12 (folate deficiency more common than B12 deficiency in coeliac disease) * Hyposplenism * Osteoporosis, osteomalacia * Lactose intolerance * Enteropathy associated T cell lymphoma of small intestine * Subfertility * Rare: oesophageal cancer

Answer 40

* Associated conditions - Dermatitis herpetiformis - Other AI conditions T1DBM, AI hepatitis - HLA-DQ2 95% and HLA-DQ8 80%

Answer 41

* Diagnosis is made by a combination of serology and endoscopic intestinal biopsy * Patients who are already taking a gluten free diet should reintroduce gluten for at least 6 weeks prior to testing

Answer 42

* Tissue transglutaminase (TTG) antibodies (IgA) are first choice according to NICE * Endomyseal anti-body (IgA) - Need to look for selective IgA deficiency which would give a false negative result

Answer 43

* 'Gold standard' - should be performed in all patients with suspected coeliac disease to confirm or exclude the diagnosis * Traditionally done in the duodenum but jejunal biopsies are also sometime performed * Findings supportive of coeliac disease: - Villous atropy - Crypt hyperplasia - Increase in intraepithelial lymphocytes - Lamina propria infiltration with lymphocytes

Answer 44

* Gluten free diet * Notable foods which are gluten free include: - Rice - Potatoes - Corn (maize) * Gluten containing cereals include: - Wheat: bread, pasta, pastry - Barley: beer - Rye - Oats - some patients with coeliac disease appear to be able to tolerate oats * TTG may be checked to check compliance with a gluten free diet * Immunisation - Patients with coeliac disease often have a degree of functional hyposplenism - For this reason, all patients with coeliac disease are offered the pneumococcal vaccine - UK recommends all people with coeliac disease to be vaccinated against pneumococcal infection and have a booster every 5 years

Answer 45

* Auto-digestion of pancreatic tissue by the pancreatic enzymes, leading to necrosis

Answer 46

* Severe epigastric pain that may radiate through to the back * Vomiting is common * Examination may reveal epigastric tenderness, ileus and low grade fever * Peri-umbilical discolouration (Cullen's sign) and flank discolouration (Grey-Turner's sign) is described but rare * Rare features associated with pancreatitis include: - Ischaemic (Purtscher) retinopathy - may cause temporary or permanent blindness

Answer 47

I GET SMASHED * Iatrogenic * Gall stones ** * ETOH ** * Trauma * Scopion bite! * Mumps * Auto-immune * Steroids * Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia * ERCP * Drugs (azathioprine, mesalazine, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate) NB Pancreatitis is 7 times more likely in someone taking mesalazine than sulfasalazine

Answer 48

* Serum amylase - raised in 75%, typically > 3 times the upper limit of normal (other causes of raised amylase include: pancreatic pseudocyst, mesenteric infarct, perforated viscus, acute cholecystitis, diabetic ketoacidosis * Serum lipase - more sensitive and specific than serum amylase, longer half life so may be useful for late presentations > 24 hours * Diagnosis of acute pancreatitis can be made without imaging if characteristic pain and amylase/lipase > 3 times normal level * However early USS imaging is important to assess the aetiology as this may affect management - e.g. patients with gallstones/biliary obstruction * Other options include contrast enhanced CT

Answer 49

* Ranson score * Glasgow score * APACHE II Features vary but common ones include: - Age >55 years - Hypocalcaemia - Hyperglycaemia - Hypoxia - Neutrophilia - Elevated LDH and AST

Answer 50

* Local - Peri-pancreatic fluid collections - Pseudocysts - Pancreatic necrosis - Pancreatic abscess - Haemorrhage * Systemic - Acute respiratory distress syndrome

Answer 51

* Mild - no organ failure or local complications * Moderately severe - transient organ failure, possible local complications * Severe - persistent >48 hours, possible local complications

Answer 52

* Fluid resuscitation - aggressive early hydration with crystalloids, in severe cases 3-6 litres of third space fluid loss may occur - Aim for a urine output of >0.5 mls/kg/hr - May also help relieve pain by reducing lactic acidosis * Analgesia - IV opioids are normally required * Nutrition - patients are routinely made nil by mouth unless there is a clear reason e.g. vomiting * Enteral nutrition should be offered to anyone with moderately severe or severe acute pancreatitis within 72 hours of presentation * NICE state do not offer prophylactic antimicrobials - Potential indications include infected pancreatic necrosis

Answer 53

* If due to gall stones patients should undergo early cholecystectomy * Patients with obstructed biliary system due to stones should undergo early ERCP * Patients who fail to settle with necrosis and have worsening organ dysfunction may require debridement, fine needle aspiration is still used by some * Patients with infected necrosis should undergo either radiological drainage or surgical necrosectomy

Answer 54

* Form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis

Answer 55

* Ascites * Abdominal pain * Fever

Answer 56

* Paracentesis - neurophil count > 250 cells/ul | * Most common organism found on ascitic fluid culture is E.coli

Answer 57

* IV ceftriaxone is usually given * Antibiotic propylaxis should be given to patients with ascites if: - Patients have had an episode of SBP - Patients with fluid protein <15 g/l and either a Child-Pugh score of at least 9 or hepatorenal syndrome * NICE recommend - Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less until the ascites has resolved * Alcoholic liver disease is a marker of poor prognosis in SBP

Answer 58

* Inflammation of the thin layer of tissue that lines the inside of the stomach called the peritoneum

Answer 59

* Inguinal hernia – found supero-medial to the pubic tubercule Account for 75% of abdominal wall hernias Men have a 25% lifetime risk of developing an inguinal hernia May be classified as being direct or indirect, distinction between the two rests on their relation to Hesselbach’s trinagle Boundaries of Hesselbach’s Triangle Medial: Rectus abdominis Lateral: Inferior epigastric vessels Inferior: Inguinal ligament Inferior epigastric vessels – Indirect hernias will be lateral to the vessels whilst direct hernias will be medial to the vessels

Answer 60

* Direct 20% – within the triangle Bowel enters through the inguinal canal ‘directly’ through a weakness in the posterior wall of the canal, termed Hesselbach’s triangle More common in older patients due to laxity of abdominal wall or significant increase in intra-abdominal pressure

Answer 61

* Indirect 80% – outside the triangle Bowel enters through the inguinal canal via the deep inguinal ring Arise from incomplete closure of the processus vaginalis, an outpouching of peritoneum allowing for embryonic testicular descent, therefore are usually deemed congenital in origin

Answer 62

* Found infero-lateral to the pubic tubercule (and medial to the femoral pulse) * More common in women, particularly multiparous ones * High risk of obstruction and strangulation * Surgical repair is required

Answer 63

All femoral hernias should be managed surgically, ideally within 2 weeks of presentation, due to the high risk of strangulation. Two different approaches can be taken with the femoral hernia surgical reduction: • Low approach – the incision is made below the inguinal ligament, which has the advantage of not interfering with the inguinal structures but does result in limited space for the removal of any compromised small bowel • High approach – the incision is made above the inguinal ligament is the preferred technique in an emergency intervention due to the easy access to compromised small bowel • The operation involves reducing the hernia and then narrowing the femoral ring with sutures medially between the pectineal and inguinal ligaments or with a mesh plug

Answer 64

* A paraumbilical hernia is a herniation occurring through the linea alba around the umbilical region* (not through the umbilicus itself). * They are also typically secondary to raised chronic intra-abdominal pressure and present as a lump around the umbilical region. * They are extremely common, with risk factors including obesity and pregnancy. * Generally they contain pre-peritoneal fat although they can occasionally contain bowel. Whilst they are a fairly common presentation in general surgery, they do not commonly strangulate

Answer 65

* Colicky right upper quadrant pain occurs postprandially * Symptoms are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal

Answer 66

* Abdominal USS * Liver function tests 2nd MRCP 3rd ERCP

Answer 67

* Biliary colic * Acute cholecystitis * Gall bladder abscess * Cholangitis * Gall stone ileus * Acalculous cholecystitis

Answer 68

* Colicky abdominal pain | * Worse after meals - fatty foods

Answer 69

* If imaging shows gallstones and history is compatible, then cholecystectomy

Answer 70

* Right upper quadrant pain * Fever * Murphy's sign * Occasionally deranged LFT's (especially Mirizzi syndrome)

Answer 71

* USS and cholecystectomy (ideally within 48 hours of presentation)

Answer 72

* Usually prodromal illness and right upper quadrant pain * Swinging pyrexia * Patient may be systemically unwell * Generalised peritonism not present

Answer 73

* USS +/- CT scanning * Ideally surgery * Sub-total cholecystectomy may be needed if Calot's triangle is hostile * If unfit, percutaneous drainage may be considered

Answer 74

* Patient severely septic and unwell * Jaundice * Right upper quadrant pain

Answer 75

* Fluid resuscitation * Broad spectrum intravenous antibiotics * Correct any coagulopathy * Early ERCP

Answer 76

* Patients may have a history of previous cholecystitis and known gallstones * Small bowel obstruction (may be intermittent)

Answer 77

* Laparotomy and removal of the gallstone from small bowel, the enterotomy must be made proximal to the site of obstruction * The fistula between the GB and duodenum should not be interfered with

Answer 78

* Patients with intercurrent illness e.g. diabetes, organ failure) * Patients systemically unwell * GB inflammation in the absence of stones * High fever

Answer 79

* If patient is fit then cholecystectomy | * If unfit then percutaneous cholecystectomy

Answer 80

* Choledocholithiasis

Answer 81

* Fat * Female * Fertile - pregnant * Forty Other notable risk factors include: * Diabetes * Crohin's disease * Rapid weight loss * Drugs: fibrates, COCP

Answer 82

* Occur due to increased cholesterol, reduced bile salts and biliary stasis * Pain occurs due to the GB contracting against a stone lodged in the cystic duct

Answer 83

* Inflammation of the gallbladder | - Number of different pathological classifications including oedematous, necrotizing, supparative and chronic

Answer 84

* Most commonly gallstones 90-95% - In a minority of people, blockage to the part of the biliary system such as the GB neck or cystic duct by gallstone causes symptoms (pain, inflammation in the GB wall, and infection) which if untreated can progress to cholecystitis * Approximately 5% presenting with acute cholecystitis do not have gallstones

Answer 85

* Obesity * Increasing age * Female gender * Higher levels of triglycerides and lower levels of LDL's * Weight cycling (up and down) * DBM * COCP * HRT * Smoking * Crohn's disease * Genetic and ethnic factors

Answer 86

* Trauma * Burns * Immobility * Starvation * Sepsis * Acute renal failure * DBM * Vascular disease * TPN * Narcotic analgesics

Answer 87

* Most common complication in people with gallstone disease

Answer 88

* Necrosis of GB * Perforation of GB * Biliary peritonitis * Peri-cholecystic abscess * Fistula (GB to duodenum) * Jaundice (due to inflammation of adjoining biliary ducts - Mirizzi's syndrome)

Answer 89

* Suspect in a person with the following symptoms: - Sudden onset constant, severe pain in the RUQ lasting several hours - Anorexia, nausea, or vomiting - Fever - Tenderness in the RUQ +/- Murphy's sign - Referred pain to the shoulder - Hx gallstones * Look for signs which could indicate a complication - RUQ palpable mass - Fever - Jaundice - More severe localised or generalised tenderness

Answer 90

* Gall stones * GORD * Acute cholangitis * Acute pancreatitis * Hepatitis * Malignancy * Appendicitis * Right lower lobe pneumonia * ACS

Answer 91

* Urgently admit to hospital for - Confirmation of the diagnosis, including abdominal USS, WCC, CRP, amylase - Monitoring of basic observations - Treatment - IV fluids, antibiotics, analgesia - Surgical assessment for cholecystectomy

Answer 92

* Increase in the BP in the portal vein, which carries the blood from the bowel and spleen to the liver - One of the consequences of chronic liver disease - Pressure in the portal vein may rise because there is a blockage, such as a blood clot, or because the resistance in the liver is increased because of scarring (fibrosis) or cirrhosis

Answer 93

* Portal hypertension and its consequence of bleeding varices are usually seen in people with moderately advanced liver disease * May be other features such as ascites (fluid in the stomach) and encephalopathy (disturbance of brain function as a result of disordered liver function)

Answer 94

* Inferior portion of the oesophagus * Superior portion of the anal canal * Round ligament of the liver

Answer 95

* Oesophageal varices - most common consequence

Answer 96

* Haemorrhoids

Answer 97

* Capute medusa

Answer 98

* Congestive splenomegaly - Anaemia - Leukopenia - Thrombocytopenia

Answer 99

* Endothelial cells lining the blood vessels release more nitric oxide - NO makes peripheral arteries dilate which makes BP drop, this stimulates release of aldosterone from the adrenal glands which tells the kidneys to retain sodium and water - In time, the plasma volume expands so much that fluid in the blood vessels is more likely to get pushed into tissues and across tissues into large open spaces like the peritoneal cavity - leading to ascites - Ascitic fluid can become infected with bacteria SBP

Answer 100

* Propanolol | - Reduces venous pressure and prevents compication

Answer 101

* Sodium restriction * Diuretics - Reduce fluid overload

Answer 102

* A to E assessment and management - Ideally resuscitation prior to endoscopy - Correct clotting FFP, vitamin K - Vasoactive agents: - Terlipressin or Octreotide - Prophylactic IV antibiotics - Endoscopy for band ligation - Sengstaken-Blakemore tube if uncontrolled haemorrhage - TIPPS if the above measures fail - connects the hepatic vein to the portal vein - can lead to an exacerbation of hepatic encephalopathy

Answer 103

* Typically benign, self limiting disease with serious outcome very rare * Incubation period 2-4 weeks * RNA picornavirus * Transmission by faecal oral spread, often in institutions * Doesn't cause chronic disease

Answer 104

* Flu-like prodrome * RUQ pain * Tender hepatomegaly * Jaundice * Cholestatic LFT's

Answer 105

* People travelling to regions high or intermediate prevalence, if aged > 1 year old * People with chronic liver disease * Patients with haemophilia * MSM * IVDU * Occupational risk

Answer 106

* Double stranded DNA hepadnavirus and is spread through exposure to infected blood or body fluids, including vertical transmission from mother to child * Incubation period is 6-20 weeks * Complications include: - Chronic hepatitis (5-10%) - ground glass hepatocytes may be seen on light microscopy - Fulminant liver failure (1%) - Hepatocellular carcinoma - Glomerulonephritis - Polyarteris nodosa - Cryobulinaemia

Answer 107

* Fever * Jaundice * Elevated liver transaminases

Answer 108

* Children born in the UK as part of normal vaccination schedule (2, 3, 4 months) * At risk workers - e.g. healthcare, IVDU, sex workers, etc * Contains HBsAg absorbed onto aluminium hydroxide adjuvant and is prepared from yeast cells using recombinant DNA technology * Around 10-15% of adults fail to respond or respond poorly to 3 doses of the vaccine - risk factors include age over 40 years, obesity, smoking, alcohol excess and immunosuppression

Answer 109

* Pegylated interferon-alpha 1st line (used to be the only treatment) - it reduces viral replication in up to 30% of chronic carriers * Better response is predicted by being female <50 years old, low HBV DNA levels, non-Asian, HIV negative, high degree of inflammation on liver biopsy * Other treatments include: - Tenovir - Entecavir - Telbivudine

Answer 110

* RNA flavivirus * Incubation period 6-9 weeks * Transmission - Needle stick 2% - Vertical from mother to child - 6% risk is higher in presence of HIV - Breast feeding is not contraindicated - Sexual intercourse transmission - 5% * No vaccine exists * Complications include - Rheumatological problems such as arthralgia, arthritis - Eye problems such as Sjorgren's syndrome - Cirrhosis - Hepatocellular cancer - Cryoglobulinaemia - Porphyria - Membranoproliferative glomerulonephritis

Answer 111

* Transient rise in serum aminotransferases / jaundice * Fatigue * Arthralgia

Answer 112

* HCV RNA is the investigation of choice to diagnose acute infection * Patients will eventually develop anti-HCV antibodies and clear the virus but the anti-bodies will remain

Answer 113

* Aims of treatment are for sustained virological response (SVR) * Defined as undetectable serum HCV RNA six months after the end of therapy * Currently a combination of protease inhibitors (e.g. daclatasvir etc) with or without ribavirin are used

Answer 114

* Ribavirin - haemolytic anaemia, cough * Women taking ribavirin should not become pregnant within 6 months of stopping as it is teratogenic * Interferon alpha - side effects - flu like symptoms, depression, fatigue, leukopenia, thrombocytopenia

Answer 115

* Single stranded RNA virus that is transmitted parenterally * It is an incomplete RNA virus that requires hepatitis B surface antigen to complete its replication and transmission cycle * Transmitted in a similar way to hep B (exchange of bodily fluids) - patients may be infected with hep B and D at the same time * Co-infection - Hep B and D at the same time * Super infection - Hep B surface antigen postive patient subsequently develops a hep D infection * Super infection is associated with risk of fulminant hepatitis, chronic hepatitis status and cirrhosis

Answer 116

* Reverse polymerase chain reaction of hepatitis D RNA

Answer 117

* RNA hepevirus * Spread by faecal-oral route * Incubation 3-8 weeks * Common in Central and South East Asia, North and West Africa and in Mexico * Cause a similar disease to hepatitis A, but carries significant mortality (about 20%) during pregnancy * Does not cause chronic disease or an increased risk of hepato-cellular cancer

Answer 118

* Develops progressively as a result of damage to the liver progressively usually over a number of years - Normal smooth liver structure becomes distorted, with nodules surrounded by fibrosis - affects the liver's synthetic, metabolic and excretory actions

Answer 119

* Compensated - when the liver can still function effectively and there are few or no, noticeable clinical symptoms * Decompensated - when the liver is damaged to the point it cannot function adequately and overt clinical complications (jaundice, ascites, variceal haemorrhage and hepatic encephalopathy) are present * Events causing decompensation include infection, portal vein thrombosis and surgery

Answer 120

* Alcohol misuse * Hepatitis B and C * Obesity (BMI of 30 kg/m2 or more) or T2 DBM Less common causes of cirrhosis include: * Autoimmune liver disease (AI hepatitis, PBC, PSC) * Genetic conditions (haemochromatosis, Wilson's disease, alpha-1 anti-trypsin deficiency, cystic fibrosis) * Long term medication such as methotrexate * Budd-Chiari syndrome or veno-occlusive disease * Sarcoidosis and glycogen storage disease

Answer 121

* Ascites * Hepatic encephalopathy * Haemorrhage from oesophageal varices * Infection * Others including: - Hepato-renal syndrome - Hepatocellular carcinoma - Portal vein thrombosis - Cardio-vascular complications including circulatory changes such as decreased BP and cirrhotic cardiomyopathy

Answer 122

* Once cirrhosis has occurred it is usually considered irreversible - People may show no symptoms for many years (compensated) - Once people start to show complications such as jaundice, ascites, variceal haemorrhage, or hepatic encephalopathy arise due to portal hypertension and/or hepatocellular failure - this marks a transition from compensated to decompensated * Prognosis can be managed to a certain extent by life style changes such as: - Treatment of underlying cause e.g. stop drinking alcohol, treat hepatitis

Answer 123

* Palpable left lobe of the liver, hepatomegaly, splenomegaly * Presence of stigmata of chronic liver disease (spida naevi, palmar erythema, white nails, muscle wasting) * Features of severe liver impairment and signs of decompensated liver disease such as: - Jaundice (examine the sclera under natural light_ - Abnormal bruising - Peripheral oedema - Ascites - Sepsis - Variceal bleeding - Encephalopathy - asterixis

Answer 124

* Low platelet count * Elevated AST: ALT ratio * High bilirubin * Low albumin * Increased prothrombin time or INR

Answer 125

* Offer transient elastography to diagnose cirrhosis for: - People with hepatitis C infection - Men who drink over 50 units of alcohol per week and women who drink over 35 units per week and have done so for several months

Answer 126

* Brand name 'Fibroscan' * Uses a 50-MHz wave passed into the liver from a small transducer on the end of an ultrasound probe * Measures the stiffness of the liver which is a proxy for fibrosis

Answer 127

* NICE recommend doing an upper endoscopy to check for varices in patients with a new diagnosis of cirrhosis * Liver USS every 6 months (+/- alpha feto protein) to check for hepato-cellular cancer

Answer 128

* NAFL is liver disease largely caused by obesity * Spectrum of disease ranging from: - Steatosis - fat in the liver - Steatohepatitis - fat with inflammation, non-alcoholic steatohepatitis (NASH) - Progressive disease may cause fibrosis and liver cirrhosis

Answer 129

* NAFLD is thought to be the hepatic manifestation of the metabolic syndrome and hence insulin resistance is thought to be the key mechanism leading to steatosis

Answer 130

* Term used to describe liver changes similar to those seen in alcoholic hepatitis in the absence of a history of alcohol abuse * Relatively common (3-4% of the population)

Answer 131

* Obesity * T2 DBM * Hyperlipidaemia * Jejunoileal bypass * Sudden weight loss/starvation

Answer 132

* Usually aysmptomatic * Hepatomegaly * ALT is typically greater than AST * Increased echogenicity on USS

Answer 133

* No evidence to support screening * If found incidentially - typically asymptomatic fatty changes on liver USS: - Enhanced liver fibrosis (ELF) blood test to check for advanced fibrosis

Answer 134

* FIB4 score * NALFD fibrosis score * Combine these scores with a FibroScan * This combination has an excellent accuracy in predicting fibrosis

Answer 135

* Lifestyle changes - Weight loss in particular - Monitoring - Ongoing research into gastric banding and insulin sensitising drugs e.g. metformin, pioglitazone

Answer 136

* Ascites is the abnormal accumulation of fluid in the abdomen

Answer 137

* According to the serum-ascites albumin gradient (SAAG) - <11g/L or - >11g/L

Answer 138

* Liver disorders are the most common cause: - Cirrhosis - Acute liver failure - Liver metastases * Cardiac - Right heart failure - Constrictive pericarditis * Other causes - Budd-Chiari syndrome - Portal vein thrombosis - Veno-occlusive disease - Myxoedema

Answer 139

* Hypoalbuminaemia - Nephrotic syndrome - Severe malnutrition e.g. Kwashiorkor * Malignancy - Peritoneal carcinomatosis * Infections - Tuberculous peritonitis * Other causes - Pancreatitis - Bowel obstruction - Biliary ascites - Post operative lymphatic leak - Serositis in connective tissue diseases

Answer 140

* Reducing dietary sodium * Fluid restriction sometimes recommended if the sodium is <125 mmol/L * Aldosterone antagonists e.g. spironolactone - Loop diuretics are often added in patients who don't respond to aldosterone agonists * Drainage of tense ascites (therapeutic abdominal paracentesis) - Large volume paracentesis for the treatment of ascites requires albumin cover - reduces paracentesis induced circulatory dysfunction and mortality * Prophylactic antibiotics to reduce the risk of SBP - NICE recommend prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litres or less until the ascites has resolved * Transjugular intrahepatic portosystemic shunt (TIPS) may be considered in some patients

Answer 141

* Associated with a high rate of ascites recurrence * Development of hepatorenal syndrome * Dilutional hyponatraemia * High mortality rate

Answer 142

* Weight loss, lethargy, diarrhoea +/- bloody, abdominal pain, perianal disease e.g. skin tags or ulcers * Raised inflammatory markers, increased faecal calprotectin, anaemia, low B12 and vitamin D * Mouth to anus skip lesions, inflammation to all layers of bowel commonly affects the terminal ileum, * Goblet cells, granulomas, bowel obstruction, fistulae (Erythema nodosum, pyoderma gangrenosum IBD)

Answer 143

* Colonoscopy – deep ulcer’s skip lesions * Small bowel enema – for examination of the terminal ileum, strictures Kantor’s string sign, proximal bowel dilation, rose thorn ulcers, fistulae

Answer 144

* Inflammation in all layers from mucosa to serosa, goblet cells, granulomas

Answer 145

* Patients should be advised to stop smoking (but may help UC) * Inducing remission – glucocorticoids (oral, topical or IV) Budesonide is an alternative Azathioprine or mercaptopurine may be used as an add on medication to induce remission (not monotherapy) Infliximab used for refractory disease and fistulating Crohn’s Metronidazole is used for peri-anal disease * Maintaining remission – azathioprine or mercaptopurine, methotrexate second line, mesalazine should be considered if the patient has had surgery 80% of patients will eventually have surgery

Answer 146

* Need to assess thiopurine methyltransferase (TPMT) activity before offering azathioprine or mercaptopurine – risks bone marrow suppression

Answer 147

* Due to common structuring in the terminal ileum – ileocaecal resection – however due to common recurrence sub-total colectomy and panproctocolectomy are done to treat the disease

Answer 148

* Bloody diarrhoea, urgency, tenesmus, abdominal pain left lower quadrant – 15-25 and 55-65 years * Submucosa ulceration, preservation of adjacent mucosa, pseudopolyps, crypt abscesses, depletion of goblet cells and mucin from gland epithelium, lead pipe appearance of colon on barium enema, loss of haustral markings

Answer 149

* Extra intestinal – Uveitis, episcleritis, erythema nodosum, primary sclerosing cholangitis, arthritis, (ankylosing spondylitis, pyoderma gangrenosum IBD)

Answer 150

Truelove & Witts – Stratifies Severity * Mild - <4 stools per day without blood, no systemic disturbance, normal ESR and CRP * Moderate – 4-6 stools per day with minimal systemic disturbance * Severe - >6 stools per day containing blood, evidence of systemic disturbance e.g. fever, tachycardia, abdominal tenderness, distention or reduced bowel sounds, anaemia, hypoalbuminaemia

Answer 151

* Mild to moderate – topical (rectal) aminosalicylates (mesalazine) 4 weeks, if remission not achieved add topical or oral corticosteroids * Extensive disease – topical (rectal) aminosalycylate and a high dose oral aminosalycylate, remission not achieved in 4 weeks stop topical and offer high dose oral aminosalycylate and oral corticosteroids * Severe colitis – should be treated in hospital, IV steroids are first line, IV ciclosporin may be used if steroid are contraindicated If no improvement after 72 hrs, consider adding ciclosporin to IV corticosteroids or consider surgery

Answer 152

* For maintaining remission - Following a severe relapse or >= 2 exacerbations in the past year - Oral azathioprine or oral mercaptopurine * Need to assess thiopurine methyltransferase (TPMT) activity before offering azathioprine or mercaptopurine – risks bone marrow suppression

Answer 153

* Multiple outpouchings of the bowel wall – commonly in the sigmoid colon – due to increasing age and low fibre diet

Answer 154

* Left iliac fossa pain and tenderness, anorexia, nausea, vomiting and diarrhoea Features of infection (pyrexia, #WCC, #CRP)

Answer 155

* Mild attacks can be treated with oral antibiotics * More significant episodes are managed in hospital. Patients are made nil by mouth, intravenous fluids and intravenous antibiotics (typical a cephalosporin + metronidazole) are given

Answer 156

* Most common acute abdominal condition requiring surgery, most common in young people age 1-20 yrs * RIF abdominal pain, McBurney’s point, Rovsing’s sign, vomiting once or twice, mild pyrexia 37.5-38c, anorexia * Typically raised inflammatory markers, neutrophilia in 80-90%

Answer 157

Investigations * PT in females, USS scan to rule out other pelvic organ pathology in females, presence of free fluid should always raise suspicion, CT scan is useful but not always common Treatment * Appendicectomy can be performed via either an open or laparoscopic approach * Prophylactic IV antibiotics to reduce wound infection * Perforated appendix require abdominal lavage * In older patients, need to be aware of underlying possible caecal malignancy or perforated sigmoid diverticular disease

Answer 158

* In small bowel obstruction, the passage of food, fluids and gas, through the small intestines becomes blocked. * Adhesions (e.g. following previous surgery) are the most common cause of small bowel obstruction, followed by hernias

Answer 159

* Diffuse, central abdominal pain * Nausea and vomiting - typically bilious vomiting * 'Constipation' with complete obstruction and lack of flatulence * Abdominal distension may be apparent, particularly with lower levels of obstruction * 'Tinkling' bowel sounds (more common in early bowel obstruction)

Answer 160

* Abdominal x-ray generally first-line imaging for suspected small bowel obstruction distended small bowel loops with fluid levels * Considered dilated if small bowel is >3cm diameter * CT is the definitive investigation and is more sensitive, particularly in early obstruction.

Answer 161

* NBM * IV fluids * NG 'Ryalls' tube with free drainage * Some may improve, others may require surgery

Answer 162

* In large bowel obstruction, the passage of food, fluids and gas, through the large intestines becomes blocked. * Causes include: - Tumour this accounts for 60% of cases of large bowel obstruction - Obstruction is the initial presenting complaint of colonic malignancy approximately 30% of cases this is particularly the case in more distal colonic and rectal tumours, as these tend to obstruct earlier due to the smaller lumen diameter - Volvulus - Diverticular disease

Answer 163

* Absence of passing flatus or stool * Abdominal pain * Abdominal distention * Nausea and vomiting are late symptoms that may suggest a more proximal lesion peritonism may be present if there is associated bowel perforation

Answer 164

* Abdominal x-ray still commonly used first-line - normal diameter limits are 10-12 cm for caecum, 8 cm for ascending colon, and 6.5 cm for recto-sigmoid - diameter greater than this is diagnostic of obstruction presence of free intra-peritoneal gas indicates colonic perforation * CT scan - high sensitivity and specificity for identifying obstruction (over 90% each) as well as identifying the aetiology of obstruction itself

Answer 165

Initial steps: - NBM - IV fluids - Nasogastric tube with free drainage * Urgency of management depends on whether perforation is suspected - if the cause of obstruction itself does not require surgery, conservative management for up to 72 hours can be trialled, after which further management may be required if there is no resolution * Around 75% will eventually require surgery * IV antibiotics will be given if perforation suspected or surgery planned Surgery * If there is any overt peritonitis or evidence of bowel perforation, emergency surgery is necessary * Irrigation of the abdominal cavity, resection of perforated segment and ischaemic bowel, and address the underlying cause of the obstruction itself

Answer 166

* Paralytic ileus is a common complication after surgery involving the bowel, especially surgeries involving handling of the bowel. There is no peristalsis resulting in pseudo-obstruction. * Paralytic ileus can also occur in association with chest infections, myocardial infarction, stroke and acute kidney injury. * Deranged electrolytes can contribute to the development of paralytic ileus, so it is important to check potassium, magnesium and phosphate. As the bowel is not functioning as normal it is better to replace electrolytes intravenously.

Answer 167

* Keep the patient NBM * Monitor fluid balance * Monitor for bowel sounds until present * Daily bloods * Encourage mobilisation * Reduce opiate analgesia as tolerated

Answer 168

* It is currently thought there are three types of colon cancer: - Sporadic (95%) - Hereditary non-polyposis colorectal carcinoma (HNPCC, 5%) - Familial adenomatous polyposis (FAP, <1%)

Answer 169

* Studies have shown that sporadic colon cancer may be due to a series of genetic mutations. For example, more than half of colon cancers show allelic loss of the APC gene. It is believed a further series of gene abnormalities e.g. activation of the K-ras oncogene, deletion of p53 and DCC tumour suppressor genes lead to invasive carcinoma

Answer 170

* HNPCC, an autosomal dominant condition, is the most common form of inherited colon cancer. * Around 90% of patients develop cancers, often of the proximal colon, which are usually poorly differentiated and highly aggressive. * Currently seven mutations have been identified, which affect genes involved in DNA mismatch repair leading to microsatellite instability. The most common genes involved are: MSH2 (60% of cases) MLH1 (30%) * Patients with HNPCC are also at a higher risk of other cancers, with endometrial cancer being the next most common association, after colon cancer

Answer 171

* The Amsterdam criteria are sometimes used to aid diagnosis: - At least 3 family members with colon cancer - The cases span at least two generations - At least one case diagnosed before the age of 50 years

Answer 172

* FAP is a rare autosomal dominant condition which leads to the formation of hundreds of polyps by the age of 30-40 years. * Patients inevitably develop carcinoma - It is due to a mutation in a tumour suppressor gene called adenomatous polyposis coli gene (APC), located on chromosome 5. * Genetic testing can be done by analysing DNA from a patient's white blood cells. * Patients generally have a total colectomy with ileo-anal pouch formation in their twenties.

Answer 173

* Patients with FAP are also at risk from duodenal tumours. * A variant of FAP called Gardner's syndrome can also feature osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts on the skin

Answer 174

* Colorectal cancer is the third most common type of cancer in the UK and the second most cause of cancer deaths. * Annually there are about 150,000 new cases diagnosed and 50,000 deaths from the disease. ``` Location of cancer (averages) rectal: 40% sigmoid: 30% descending colon: 5% transverse colon: 10% ascending colon and caecum: 15% ```

Answer 175

* Cancer of the colon is nearly always treated with surgery. * Stents, surgical bypass and diversion stomas may all be used as palliative adjuncts. * Resectional surgery is the only option for cure in patients with colon cancer. The procedure is tailored to the patient and the tumour location. The lymphatic drainage of the colon follows the arterial supply and therefore most resections are tailored around the resection of particular lymphatic chains (e.g. ileo-colic pedicle for right sided tumours). * Some patients may have confounding factors that will govern the choice of procedure, for example a tumour in a patient from a HNPCC family may be better served with a panproctocolectomy rather than segmental resection.

Answer 176

* The management of rectal cancer is slightly different to that of colonic cancer. * This reflects the rectum's anatomical location and the challenges posed as a result. * Tumours located in the rectum can be surgically resected with either an anterior resection or an abdomino-perineal excision of rectum (APER). * The technical aspects governing the choice between these two procedures can be complex to appreciate and the main point to appreciate for the exam is that involvement of the sphincter complex or very low tumours require APER.

Answer 177

* Diagnosis should be considered if the patient has had the following for at least 6 months: - Abdominal pain, and/or - Bloating, and/or - Change in bowel habit

Answer 178

* Diagnosis should be confirmed if the patient has abdominal pain relieved by defaecation or associated with altered bowel frequency stool form, in addition to 2 of the following 4 symptoms: - Altered stool passage (straining, urgency, incomplete evacuation) - Abdominal bloating (more common in women than men), distention, tension or hardness - Symptoms made worse by eating - Passage of mucus

Answer 179

* Primary care investigations - FBC - ESR/CRP - Coeliac disease screen (tissue transglutaminase antibodies)

Answer 180

* Red flag features should be enquired about: - Rectal bleeding - Unexplained/unintentional weight loss - Family history or bowel or ovarian cancer - Onset after 60 years of age

Answer 181

* Dietary advice - Have regular meals, take time to eat - Avoid missing meals or long gaps between eating - Drink at least 8 cups of fluid per day – water and non-caffeinated drinks - Restrict to 3 cups tea/coffee per day - Reduce fizzy drinks - Reduce intake of high fibre food and resistant starch - Limit to 3 portions of fresh fruit per day - For wind and bloating increase intake of oats e.g. porridge and linseeds

Answer 182

* First line pharmacological treatment according to symptoms: - Pain – antispasmodic agents - Constipation – laxatives but avoid lactulose - Diarrhoea – loperamide is first line * Patients with constipation not responding to conventional laxatives linaclotide may be considered, if: - Optimal or maximum tolerated doses of previous laxatives from different classes have not helped - Constipation for at least 12 months

Answer 183

* Second line pharmacological treatment - Low dose TCA’s e.g. amitriptyline 5-10mg are used in preference to SSRI’s Consider CBT referral if not responding to pharmacological treatments after 12 months

Answer 184

* Associated with childbirth and rectal intussceception. * May be internal or external * Associated with CF – due to bulky stools

Answer 185

* Conservative - monitor | * Surgical – rectopexy

Answer 186

* Painless rectal bleeding is the most common symptom * Pruritus * Pain: usually not significant unless piles are thrombosed * Soiling may occur with 3rd or 4th degree piles

Answer 187

* Internal Originate below the dentate line Prone to thrombosis, may be painful * External Above dentate line Do not cause pain

Answer 188

* Soften stools – increase dietary fibre and fluid intake * Topical local anaesthetics and steroids for symptomatic relief * Rubber band ligation – superior to injection scleropathy * Surgery reserved for large symptomatic haemorrhoids not responding to outpatient treatment * Newer treatments include: Doppler guided haemorrhoid artery ligation, stapled haemorrhoidopexy

Answer 189

* Collection of pus within the subcutaneous tissue of the anus that has tracked from the tissue surrounding the anal sphincter

Answer 190

* E.Coli | * Staph aureus

Answer 191

* MRI or trans-perineal USS | * MRI gold standard but not commonly used unless IBD or complicated

Answer 192

* Usually managed with incision and drainage * Left open or packed for 3-4 weeks * Antibiotics if there is systemic upset

Answer 193

* Constipation * IBD esp. Crohn’s * STI’s

Answer 194

* Painful, bright red bleeding | * 90% occur posterior midline

Answer 195

<6 weeks = acute ++fibre and ++fluid intake Bulk forming laxatives – Fybogel Analgesia >6 weeks = chronic Continue with above measures Topical GTN is first line If not effective after 8 weeks – surgical sphinctorectomy or botulinum toxin

Answer 196

* Volvulus may be defined as torsion of the colon around it's mesenteric axis resulting in compromised blood flow and closed loop obstruction

Answer 197

* Sigmoid volvulus (around 80% of cases) describes large bowel obstruction caused by the sigmoid colon twisting on the sigmoid mesocolon

Answer 198

* Older patients * Chronic constipation * Chagas disease * Neurological conditions e.g. Parkinson's disease, Duchenne muscular dystrophy * Psychiatric conditions e.g. schizophrenia

Answer 199

* Constipation * Abdominal bloating * Abdominal pain * Nausea/vomiting

Answer 200

* Usually diagnosed on the abdominal film sigmoid volvulus: large bowel obstruction (large, dilated loop of colon, often with air-fluid levels) + coffee bean sign * Caecal volvulus: small bowel obstruction may be seen

Answer 201

* Sigmoid volvulus: rigid sigmoidoscopy with rectal tube insertion * Caecal volvulus: management is usually operative. Right hemicolectomy is often needed

Answer 202

* Coffee bean sign

Answer 203

* Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach's plexus i.e. LOS contracted, oesophagus above dilated. * Achalasia typically presents in middle-age and is equally common in men and women

Answer 204

- Dysphagia to both liquids and solids - Typically variation in severity of symptoms - Heart burn - Regurgitation of food – cough, aspiration pneumonia - Malignant change in small number of patients

Answer 205

* Oesophageal manometry – excessive LOS tone which doesn’t relax on swallowing, considered most important test * Barium swallow – shows grossly expanded fluid level, bird’s beak appearance

Answer 206

* Balloon dilation 1st line – better recovery, lower risk than surgery * Surgery – Heller cardiomyotomy if persistent or recurrent symptoms * Intra-sphincteric injection for high risk patients with botulinum toxin * Calcium channel blockers or nitrates have a role but limited by side effects

Answer 207

* The term 'dyspepsia' is used to describe a complex of upper gastrointestinal tract symptoms which are typically present for four or more weeks, including upper abdominal pain or discomfort, heartburn, acid reflux, nausea and/or vomiting

Answer 208

* GORD - most common * Peptic ulcer disease (gastric or duodenal ulcers) * Functional dyspepsia (non-ulcer dyspepsia) Other causes include: * Barrett's oesophagus * Upper GI malignancy

Answer 209

* Symptoms can occur in about 40% of the population each year * 5% of the population are referred to the GP each year

Answer 210

* All patients with the following: - Dysphagia - Upper abdominal mass consistent with stomach cancer - Patients aged >= 55 years with weight loss AND any of the following: - Upper abdominal pain - Reflux - Dyspepsia Should have an urgent (within 2 weeks) endoscopy

Answer 211

* Patients with haematemesis * Patients aged >=55 years who have got: - Treatment resistant dyspepsia or - Upper abdominal pain with low haemoglobin levels or - Raised platelet count with any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain - Nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper abdominal pain Should have a non-urgent (within 6 weeks ??) endoscopy

Answer 212

1. Review medications for possible causes of dyspepsia 2. Lifestyle advice 3. Trial of full dose PPI for one month OR test and treat approach for H. Pylori - If symptoms persist after either of the above approaches then the alternative approach should be tried

Answer 213

* Initial diagnosis: NICE recommend using a carbon 13 urea breath test or a stool antigen test or laboratory serology where its performance has been locally validated * Test of cure - No need to check for H. Pylori eradication if symptoms have resolved following test and treat * However if repeat testing is required should use carbon-13 urea breath test

Answer 214

* Inflammatory condition which ultimately can affect both exocrine and endocrine functions of the pancreas * Around 80% of cases are due to alcohol excess - 20% of cases unexplained

Answer 215

* Genetic - CF, haemochromatosis | * Ductal obstruction - tumours, stones, structural abnormalities including pancreas divisum and annular pancreas

Answer 216

* Pain - typically worse 15 to 30 minutes following a meal * Steatorrhoea - symptoms of pancreatic insufficiency usually develop between 5 and 25 years after the onset of pain * DBM - typically occurs more than 20 years after symptoms begin

Answer 217

* Abdominal x-ray shows pancreatic calcification in 30% of cases * CT is more sensitive at detecting pancreatic calcification. Sensitivity is 80%, specificity is 85% * Functional tests: faecal elastase may be used to assess exocrine function if imaging inconclusive

Answer 218

* Conservative - stop drinking alcohol * Medical - Pancreatic enzyme supplements - Analgesia - Antioxidants - limited evidence

Answer 219

* Localised collections of pus, usually underneath the right or left hemi-diaphragm * Other sites include the lesser sac beneath the liver and the hepato-renal pouch * Usually a result of a breach in the integrity of the peritoneum * Sub phrenic abscesses are the most common intra-abdominal abscess

Answer 220

* Acute appendicitis * Perforated peptic ulcer * Perforated GB, producing a right sided subphrenic abscess and biliary surgery * Bowel surgery and subsequent peritoneal faecal contamination Other causes include infection for example haematoma after a splenectomy

Answer 221

* One who develops features of toxicity 2 to 21 days after making an initial recovery from an episode of peritonitis or an operation: - Swinging fever - Malaise, nausea, weight loss - Upper abdominal pain that radiates to the shoulder tip - SOB due to lower lobe lung collapse or development of a pleural effusion

Answer 222

* USS or abdominal CT: localises collections of pus * WCC often a leucoytosis of around 20,000 * Chest x-ray - High diaphragm on the affected side - May be gas and fluid beneath the diaphragm - If there is a pleural effusion then this is seen on chest x-ray

Answer 223

* Drainage - can use USS or via open operation * If the abscess is diagnosed early and has no air or fluid level then this may be treated with broad spectrum antibiotics e.g. gentamicin, benzylpenicillin and metronidazole * If symptoms persist for more than 5 days then conservative management should be abandoned and abscess drainage performed

Answer 224

* Staphylococcus aureus in children | * Escherichia coli in adults

Answer 225

* Drainage (typically percutaneous) and antibiotics * Amoxicillin + ciprofloxacin + metronidazole * If penicillin allergic: ciprofloxacin + clindamycin

Answer 226

Most common * Cholangiocarcinoma * Hepatocellular carcinoma Others * Hepatoblastoma * Sarcomas (rare) * Lymphomas * Carcinoids (most often secondary) * Overall metastatic disease accounts for 95% of all liver malignancies making primary liver tumours comparitively rare

Answer 227

* Account for 75% of primary liver tumours * Occur on a background of chronic inflammatory activity * Most cases arise in cirrhotic livers or those with chronic hepatitis B infection * Majority of patients 80% present with existing liver cirrhosis, with a mass discovered on screening USS

Answer 228

* CT/MRI * AFP elevated in almost all cases * Biopsy should be avoided * Cases of doubt CT and AFP measurements are the preferred strategy

Answer 229

* Staging with liver MRI, chest, abdo, pelvis CT * Surgical resection is the mainstay of treatment in operable cases * Transplant is a consideration if resection is possible * Survival - poor prognosis 15% at 5 years

Answer 230

* Second most common type of primary liver malignancy * Arise in the bile duct - 80% of tumours arise in the extra hepatic biliary tree * Most patients present with jaundice at this stage most will have disease that is not resectable

Answer 231

* Primary sclerosing cholangitis | * Typhoid and liver flukes are also major risk factors in deprived countries

Answer 232

* Typically an obstructive picture on liver function tests * CA 19-9, CEA and CA125 often elevated * CT/MRI are the main imaging methods of choice

Answer 233

* Surgical resection offers the best chance of cure * Local invasion of peri-hilar tumours is a particular problem and this coupled with lobar atrophy will often contra indicate surgical resection * Palliation of jaundice is important, although metallic stents should be avoided in those considered for resection

Answer 234

* Poor - 5-10% 5 year survival

Answer 235

* Rapid onset of hepatocellular dysfuntion leading to a variety of systemic complications

Answer 236

* Paracetamol overdose * Alcohol * Viral hepatitis (A or B) * Acute fatty liver of pregnancy

Answer 237

* Jaundice * Coagulopathy - raised prothrombin time * Hypoalbuminaemia * Hepatic encephalopathy * Renal encephalopathy * Renal failure is common (hepato-renal syndrome)

Answer 238

* LFT's do not always accurately reflect the synthetic function of the liver * Best assessed by looking at the prothrombin time and albumin level

Answer 239

* Excess absorption of ammonia and glutamine from bacterial breakdown of proteins in the gut * Often associated with acute liver failure, may also be associated with chronic disease * Has also been associated with transjugular intrahepatic portosystemic shunting (TIPPS)

Answer 240

* Confusion, altered GCS * Asterix: liver flap, arrhythmic negative myoclonus with a frequency of 3-5 Hz * Constructional apraxia - inability to draw a 5 pointed star * Triphasic slow waves on EEG * Raised amonia level

Answer 241

West-Haven Criteria * Grade I - irritability * Grade II - confusion, inappropriate behaviour * Grade III - incoherent, restless * Grade IV - coma

Answer 242

* Infection e.g. spontaneous bacterial peritonitis * GI bleed * Post TIPPS * Constipation * Drugs: sedatives, diuretics * Hypokalaemia * Renal failure * Increased dietary protein

Answer 243

* Treat any underlying precipitant cause * NICE recommend lactulose first line, with the addition of rifaximin for the secondary prophylaxis of hepatic encephalopathy * Lactulose - promotes excretion of ammonia and increasing metabolism of ammonia by gut bacteria * Anti-biotics such as rifiximin are thought to modulate gut flora resulting in decreased ammonia production * Other options include embolisation of portosystemic shunts and liver transplant in selected patients

Answer 244

* Most accepted theory is that vasoactive mediators cause splanchnic vasodilation which in turn reduces the systemic vascular resistance - results in under filling of the kidneys * This is sensed by the juxtaglomerular apparatus which then activates the RAAS system, causing renal vasoconstriction which is not enough to counter balance the effects of the splanchnic vasodilation

Answer 245

* Type 1 HRS - Rapidly progressive - Doubling of serum creatinine to >221mmol/L or a halfing of creatinine clearance to less than 20ml/min over a period of <2 weeks - Very poor prognosis * Type 2 HRS - Slowly progressive - Poor prognosis, but patients may live for longer

Answer 246

* Vasopressin analogues - terlipressin to cause vasocontriction of the splanchnic circulation * Volume expansion with 20% albumin * TIPPS

Answer 247

* Familial adenomatous polyposis * MYH associated polyposis * Peutz-Jeghers syndrome * Cowden disease * HNPCC (Lynch syndrome)

Answer 248

* Mutation of APC gene * 80% cases dominant * Typically over 100 colonic adenomas * Cancer risk of 100% * 20% are new mutations

Answer 249

* Annual flexible sigmoidoscopy (if known) | * Polyps found = resectional surgery and pouch vs sub total colectomy

Answer 250

* Biallelic mutation of mut Y human homolgue on chromosome 1p, recessive * Multiple polyps, right side more common than in FAP * 100% cancer risk by age 60

Answer 251

* Once identified, resection and ileoanal pouch reconstruction is recommended * Regular colonoscopy * Associated with increased risk of breast cancer

Answer 252

* STK11 (LKB1) mutation on chromosome 19 * Multiple benign intestinal hamartomas * Episodic obstruction and intussusception * Increased risk of GI cancers (colorectal and gastric)

Answer 253

* Annual examination * Pan-intestinal endoscopy every 2-3 years Associations * Malignancies at other sites - classical pigmentation pattern

Answer 254

* Mutation of PTEN gene on chromosome 10q22, dominant * Macrocephaly * Multiple intestinal harmartomas * Multiple trichilemmomas * 89% risk of cancer at any site * 16% risk colorectal cancer

Answer 255

* Targeted individualised screening Associations * Breast cancer risk (81%) * Thyroid cancer and non-toxic goitre * Uterine cancer

Answer 256

* Germline mutations of DNA mismatch repair genes * Colo rectal cancer 30-70% * Enometrial cancer 30-70% * Gastric cancer 5-10% * Scanty colonic polyps may be present * Colonic tumours likely to be right sided and mucinous

Answer 257

* Colonoscopy every 1-2 years from age 25 * Consideration of prophylactic surgery * Extra colonic surveillance recommended due to increased risk of developing

Answer 258

* Lump in the midline between umbilicus and the xiphisternum * Most common in men aged 20-30 years * Through the fibres of the linea alba * RF’s – raised intra-abdominal pressure, pregnancy, ascites

Answer 259

``` * Relatively rare 1.5/100,000 Older age 85-89 yrs average Risk factors - HPV 16&18 – MSM - HIV +ve with immunosuppressive medication - Smoking Features, subacute onset of: - Peri-anal pain and bleeding - Palpable lesion - Faecal incontinence ```

Answer 260

* Wrongly called a thrombosed or external pile * Collection of blood within the skin around the anus usually caused by minor trauma * Typical history is of a moderate sized swelling at the anal verge which is tense and intensely painful

Answer 261

* Conservative - Leave alone and will resolve by itself in a couple of weeks but pain and swelling through this time, stool softeners and analgesia * Surgical - Local anaesthetic surgical excision, wound is left open to allow drainage

Answer 262

* Usually due to previous ano-rectal abscess | Intersphincteric, transphincteric, suprasphincteric and extra-sphincteric

Answer 263

Imaging Fistulography – if extrasphincteric fistula suspected Endoanal USS – determine complexity of the fistula MRI – gold standard for fistula-in-ano imaging

Answer 264

* Fistulotomy - setons, fibrin glue, anal fistula plug

Answer 265

Describes the metabolic abnormalities which occur on feeding a person following a period of starvation. Occurs when an extended period of catabolism ends abruptly with switching to carbohydrate metabolism. Metabolic consequences include: - Hypophosphataemia - Hypokalaemia - Hypomagnesaemia – can lead to torsades de points - Abnormal fluid balance Overall can lead to organ failure.

Answer 266

* Alcohol excess * Acute liver failure * DKA * Refeeding syndrome! * Primary hyperparathyroidism * Osteomalacia

Answer 267

* RBC haemolysis * WC and platelet dysfunction * Muscle weakness and rhabdomyolysis * CNS dysfunction

Answer 268

In order to reduce the risk, patients at risk of refeeding syndrome may be identified by the following: High risk if one or more: - BMI <16 kg/m2 - Unintentional weight loss >15% over 3-6 months - Little nutritional intake >10 days - Hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high) If two or more of the following: - BMI <18.5 kg/m2 - Unintentional weight loss >10% over 3-6 months - Little nutritional intake >5 days - History of alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids

Answer 269

* NICE recommend that if a patient hasn’t eaten for >5 days, aim to re-feed at no more than 50% of requirements for the first 2 days - Start at up to 10 kcal/kg/day increasing to full needs over 4-7 days - Start immediately before and during feeding: oral thiamine 200-300mg/day, vitamin B co strong 1 tds and supplements - Give K+ (2-4 mmol/kg/day), phosphate (0.3-0.6 mmol/kg/day), magnesium (0.2-0.4 mmol/kg/day)

List I - Core Conditions Flashcards

(295 cards)