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Year 3 OSCE > Miscellaneous Gastroenterology > Flashcards

Miscellaneous Gastroenterology Flashcards

1
Q

Features of appendicitis

A

Central pain radiating to RIF
Anorexia
Rovsings sign (press LIF, pain in RIF)
Guarding on abdominal palpation
Rebound tenderness in the RIF (increased pain when suddenly releasing the pressure of deep palpation)
Percussion tenderness (pain and tenderness when percussing the abdomen)
Neutrophil predominant leukocytosis

NB- Rebound tenderness and percussion tenderness suggest peritonitis, potentially indicating a ruptured appendix.

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2
Q

Investigations and management for appendicitis

A

Clinical diagnosis, but USS useful in young females (pelvic organ pathology)
Laparoscopic appendicectomy with prophylactic IV ABX

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3
Q

How to calculate units of alcohol

A

Number of millilitres by the %, then divide by 1000

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4
Q

Alcoholic ketoacidosis

A

Non diabetic euglycaemic form of ketoacidosis (often alcoholics)

Metabolic acidosis with elevated anion gap, ketonaemia, normal or low glucose

Treat (vitamin B1) with infusion of saline and thiamine (always correct thiamine before glucose)

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5
Q

What are carcinoid tumours

A

Cause carcinoid syndrome- typically liver metastases that release serotonin systematically (also lung)- can also release pituitary hormones eg. ACTH

Features- flushing, diarrhoea, bronchospasm, hypotension, valvular stenosis, pellagra

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6
Q

Investigations and management or carcinoid tumours

A

Urinary 5-HIAA

Management- somatostatin analogue eg. Octreotide

NB0 cardiac manifestations: pulmonary stenosis and tricuspid insufficiency

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7
Q

Risk factors for bowel ischaemia

A

Increased age
Emboli- AF, malignancy, infective endocarditis
CVD risk factors
Cocaine

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8
Q

Features of bowel ischaemia

A

Abdominal pain
Rectal bleeding
Diarrhoea
Fever
Bloods- elevated WCC, lactic acidosis

CT- investigation of choice

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9
Q

Acute mesenteric ischameia

A

Sudden onset acute abdominal pain
Out of keeping with physical exam findings
Urgent surgery required

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10
Q

Chronic mesenteric ischaemia

A

Intestinal angina
Colicky, intermittent, abdominal pain

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11
Q

Ischaemic colitis

A

Acute but transient compromise to blood flow in large bowel- inflammation ulceration and haemorrhage
Most likely to occur in splenic flexture
Thumb printing on x ray
Supportive management
Surgery in severe cases

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12
Q

Metoclopramide

A

D2 receptor antagonist

Used in management of nausea, GORD, gastroporeis, migraine

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13
Q

Adverse effects of metoclopramide

A

Extrapyramidal eg, oculogyric crisis, tardive dyskinesia, Parkinsonism
Hyperprolactinameia

Avoid in bowel obstruction, may be helpful in paralytic ileus

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14
Q

Peutz Jeghers syndrome

A

Hamartomatous polyps in small bowel
Pigmented lesions on lips, oral mucosa, face, palms, soles
Intestinal obstruction (intussusception)
GI bleeding

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15
Q

Adverse effects of PPI’s

A

Hyponatraemia, hypomagnesia
Osteoporosis- fracture risk
Colitis
Increased risk of c diff infection

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16
Q

Features of refeeding syndrome

A

Hypophoshphataemia
Hypokalaemia
Hypomagnesia
Abnormal fluid balance

If someone hasn’t eaten for 5 days, feed at no more than 50% of their requirements for 2 days

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17
Q

Small bowel bacterial overgrowth syndrome

A

Diabetes Mellitus and scleroderma

Similar features to IBS

Hydrogen breath test for diagnosis

Correct underlying disorder and rifaximin (ABX)

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18
Q

Spontaneous bacterial peritonitis

A

Usually seen in patients with ascites secondary to liver cirrhosis

Can be asymptomatic so have a low threshold for ascitic fluid culture, Fever, Abdominal pain, Deranged bloods (raised WBC, CRP, creatinine or metabolic acidosis), Ileus, Hypotension

Paracentesis- neutrophils >250, usually E. coli when ascitic fluid is cultured

Give prophylaxis to people who have had this before

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19
Q

Vitamin A

A

Retinol

Deficiency causes nighttime blindness

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20
Q

Vitamin B1

A

Thiamine

Deficiency- WKS, wet beri beri (heart)

Causes of deficiency- alcohol excess, malnutrition

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21
Q

Dry beri beri

A

Peripheral neuropathy

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22
Q

Wet beri beri

A

Dilated cardiomyopathy

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23
Q

Vitamin B3

A

Niacin

Deficiency causes pellagra- dermatitis, diarrhoea, dementia

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24
Q

Vitamin B6

A

Pyridoxine

Peripheral neuropathy and sideroblastic anaemia

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25
Q

Vitamin C

A

Ascorbic acid

Deficiency (scurvy) - gingivitis, loose teeth, poor wound healing, bleeding from gums, haematuria, epistaxis, general malaise, echymosis, easy bruising, Sjogrens, arthralgia

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26
Q

Zolinger Ellison syndrome

A

Syndrome caused by excess gastrin
Usually a duodenal or pancreatic tumour
MEN1
Diagnosis- fasting gastric levels

Features- gastric duodenal ulcers, diarrhoea, malabsorption

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27
Q

Ileostomy

A

Right iliac fossa
Spouted
Liquid

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28
Q

Colostomy

A

Often LHS
Flushed to skin (not spouted)
Solid output

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29
Q

Loop ileostomy

A

Used to de function colon following resection eg. Rectal cancer surgery
Does not decompress colon
Usually right iliac fossa
Reversible

The bowel is partially opened and folded so that there are two openings on the skin side-by-side, attached in the middle.

NB- wouldn’t be created after a pancolectomy (as there is nothing to attach the ileum to after reversal has been carried out- only used when there is colon left that can be re-attached after a certain time)

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30
Q

End ileostomy

A

Following complete excision of colon
Reversal difficult

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31
Q

Loop colostomy

A

Reversible
Serves to defunction and decompress a distal segment of colon in obstructing cancers

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32
Q

Features of anal cancer

A

Perianal pain
Perianal bleeding
Palpable lesion
Faecal incontinence

33
Q

Investigations for anal cancer

A

DRE, anoscopy with biopsy, check inguinal lymph nodes
Imaging
Check HIV status

34
Q

Risk factors for an anal fissure

A

Constipation
IBD
STI- HIV, syphilis, herpes

35
Q

Features of an anal fissure (fissure in ano)

A

Painful, bright red rectal bleeding
90% occur on the posterior midline, if they are in alternate location, think of another cause eg, Crohn’s disease

36
Q

Management of an acute anal fissure

A

Soften stool- dietary advice, bulk forming laxative
Lubricants before defeacation
Topical anaesthetic or analgesia

37
Q

Management of a chronic anal fissure

A

Same measures as acute fissure
Topical GTN
IF GTN doesn’t work after 8 weeks- sphincterectomy or Botox

38
Q

Pruritus ani

A

Itchy anus

39
Q

Anal fistula

A

Usually due to a previous anorectal abscess

40
Q

Rectal prolapse

A

Associated with childbirth and rectal intussception
Internal or external

41
Q

Solitary rectal ulcer

A

Chronic straining and constipation

42
Q

Causes of large bowel obstruction

A

Tumour
Volvulus
Diverticula disease
Adhesions
Hernias
Strictures

NB- not ileus as there is no obstruction in ileus, just a lack of peristalsis/movement

43
Q

Clinical features of large bowel obstruction-+

A

Symptoms and signs of underlying cause eg. CRC
Absence of flatus and stool
Abdominal pain and distension
Nausea and vomiting (green bilious vomit)
Peritonism if perforation
Tinkling” bowel sounds may be heard in early bowel obstruction

44
Q

Investigations for large bowel obstruction

A

Acute abdomen investigations, A-E assessment etc.
Abdominal x ray
CT scan

45
Q

Management of large bowel obstruction

A

NBM, NG tube, IV fluids
Conservative management for 72 hours can be trialled if no perforation
Surgery (resection etc.) + IV antibiotics

46
Q

Features of a perianal abscess

A

Pain around the anus, worse on sitting
Hardened tissue in the anal region
Pus like discharge from anus
Long-standing- may have systemic features

Associated with crohns, DM, underlying malignancy

47
Q

Treatment of a perianal abscess

A

Incision and drainage
Antibiotics if systemic symptoms

48
Q

Thrombosed haemorrhoids

A

Significant pain and tender lump
Purple, oedematous perianal mass
If within 72 hours- excision. Otherwise, stool softeners, ice packs, analgesia

49
Q

Features of a volvulus

A

Twisting of the colon around itself

Constipation
Abdominal pain and bloating
Nausea and vomiting

50
Q

Management of volvulus

A

Refer to general surgeons
Sigmoid- rigid sigmoidoscopy with rectal tube insertion
Caecal- operative (right hemicolectomy sometimes required)

51
Q

Complications of a laparoscopy

A

Anaesthetic risk
Vasovagal (bradycardia) in response to abdominal distension
Surgical emphysema
Injury to GI tract
Injury to blood vessels

52
Q

Management of malignant surgical jaundice

A

Stent

53
Q

Diagnosing surgical jaundice

A

Observations and abdominal examination
Bloods- FBC UE LFT clotting screen CRP ESR etc.
RUQ USS of liver and biliary tree
CT abdomen or ERCP/MRCP

54
Q

Melanosis coli

A

Laxative abuse

55
Q

Medication to avoid in bowel obstruction

A

Metoclopramide

56
Q

Management of SBP

A

Take an ascitic culture prior to giving antibiotics
Usually treated with an IV cephalosporin such as cefotaxime

57
Q

Hepatorenal syndrome

A

Hepatorenal syndrome occurs in liver cirrhosis. Hypertension in the portal system leads to dilation of the portal blood vessels, stretched by large amounts of blood pooling there. This leads to a loss of blood volume in other areas of the circulation, including the kidneys. This leads hypotension in the kidney and activation of the renin-angiotensin system. This causes renal vasoconstriction, which combined with low circulation volume leads to starvation of blood to the kidney. This leads to rapid deteriorating kidney function.

58
Q

What is ileus

A

a condition affecting the small bowel, where the normal peristalsis that pushes the contents along the length of the intestines, temporarily stops. It may be referred to as paralytic ileus or adynamic ileus.

59
Q

What is ileus

A

a condition affecting the small bowel, where the normal peristalsis that pushes the contents along the length of the intestines, temporarily stops. It may be referred to as paralytic ileus or adynamic ileus.

60
Q

Causes of ileus

A

Injury to the bowel
Handling of the bowel during surgery
Inflammation or infection in, or nearby, the bowel (e.g., peritonitis, appendicitis, pancreatitis or pneumonia)
Electrolyte imbalance (e.g., hypokalaemia or hyponatraemia)

61
Q

Features of ileus

A

Akin to obstruction, namely;

Vomiting (particularly green bilious vomiting)
Abdominal distention
Diffuse abdominal pain
Absolute constipation and lack of flatulence
Absent bowel sounds (as opposed to the “tinkling” bowel sounds of mechanical obstruction)

62
Q

Management of ileus

A

Supportive- will resolve on its own eg.
Nil by mouth or limited sips of water
NG tube if vomiting
IV fluids to prevent dehydration and correct the electrolyte imbalances
Mobilisation to helps stimulate peristalsis
Total parenteral nutrition (TPN) may be required whilst waiting for the bowel to regain function

63
Q

What is a volvulus?

A

a condition where the bowel twists around itself and the mesentery that it is attached to (either sigmoid or caecal- X ray shows either coffee bean or foetus sign)

64
Q

Volvulus risk factors

A

Neuropsychiatric disorders (e.g., Parkinson’s)
Nursing home residents
Chronic constipation
High fibre diet
Pregnancy
Adhesions

65
Q

Features of a volvulus

A

Akin to bowel obstruction, namely;

Vomiting (particularly green bilious vomiting)
Abdominal distention
Diffuse abdominal pain
Absolute constipation and lack of flatulence

66
Q

Management of a volvulus

A

Conservative- same as obstruction eg. fluids, analgesia, NBM, NG tube etc.
Surgical- endoscopic resection for sigmoid volvulus (no peritonitis), or laparotomy/ colectomy etc.

67
Q

Complications of stomas

A

Psycho-social impact
Local skin irritation
Parastomal hernia
Loss of bowel length leading to high output, dehydration and malnutrition
Constipation (colostomies)
Stenosis
Obstruction
Retraction (sinking into the skin)
Prolapse (telescoping of bowel through hernia site)
Bleeding
Granulomas causing raised red lumps around the stoma

68
Q

Cholangiocarcinoma

A

Cancer arising from the bile ducts. Key risk factors include;

Primary sclerosing cholangitis
Liver flukes (a parasitic infection)

69
Q

Features of cholangiocarcinoma

A

Obstructive jaundice
Unexplained weight loss
Right upper quadrant pain
Palpable gallbladder (swelling due to an obstruction in the duct distal to the gallbladder)
Hepatomegaly

70
Q

Most appropriate analgesia following an abdominoperineal resection

A

Epidural

71
Q

Investigation of choice in severe colitis

A

Flexible sigmoidoscopy, not colonoscopy

72
Q

Differentials for an abdominal mass

A

ovarian pathology – ovarian cyst/benign tumour, ovarian cancer
tubal pathology – tubo-ovarian abscess, tubal malignancy (treat as ovarian)
uterine pathology – pregnancy, fibroids/benign tumour, uterine cancer
urological pathology – distended bladder, pelvic kidney, transplanted kidney
GI pathology – the 6 Fs: fat, fluid, flatus, faeces, fetus, filthy big tumour
other abdominal pathology – primary peritoneal cancer, retroperitoneal sarcoma.

73
Q

Hiatus hernia

A

sliding: accounts for 95% of hiatus hernias, the gastroesophageal junction moves above the diaphragm
rolling (paraoesophageal): the gastroesophageal junctions remains below the diaphragm but a separate part of the stomach herniates through the oesophageal hiatus

Features
heartburn
dysphagia
regurgitation
chest pain

Investigation
barium swallow is the most sensitive test
given the nature of the symptoms many patients have an endoscopy first-line, with a hiatus hernia being found incidentally

Management
-all patients benefit from conservative management e.g. weight loss
-medical management: proton pump inhibitor therapy
-surgical management: only really has a role in symptomatic paraesophageal hernias

74
Q

Femoral Hernia

A

inferolateral to the pubic tubercle
cough impulse is often absent
More common in women
Incarceration- where the herniated tissue cannot be reduced
Strangulation- high risk in femoral hernias (repair is a necessity, no hernia belts)

75
Q

Inguinal hernia

A

superior and medial to the pubic tubercle
disappears on pressure or when the patient lies down
treat medically fit patients even if they are asymptomatic(hernia belt if not fit for surgery)
-unilateral inguinal hernias are generally repaired with an open approach
-bilateral and recurrent inguinal hernias are generally repaired laparoscopically

anatomical differences between indirect (hernia through the inguinal canal) and direct hernias (through the posterior wall of the inguinal canal)
following an open repair patients return to non-manual work after 2-3 weeks and following laparoscopic repair after 1-2 weeks

NB- indirect inguinal hernias may occur in infants (others are more common in adults)

NB- congenital inguinal hernias should be surgically repaired soon after diagnosis as at risk of incarceration

NB- indirect inguinal hernias can be in the scrotum (NOT A SCROTAL HERNIA- ITS indirect INGUINAL)

76
Q

Complications of an ileostomy

A

May develop significant volume depletion, electrolyte and acid-base disturbances (metabolic acidosis) if the ileostomy output increases or if dietary intake is disrupted or altered

77
Q

Investigation of choice for SBO

A

CT abdomen

78
Q

Spigelian hernia

A

seen lateral to the umbilicus

Year 3 OSCE (61 decks)

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