Miscellaneous Gastroenterology Flashcards
Features of appendicitis
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.
Investigations and management for appendicitis
Clinical diagnosis, but USS useful in young females (pelvic organ pathology)
Laparoscopic appendicectomy with prophylactic IV ABX
How to calculate units of alcohol
Number of millilitres by the %, then divide by 1000
Alcoholic ketoacidosis
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)
What are carcinoid tumours
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
Investigations and management or carcinoid tumours
Urinary 5-HIAA
Management- somatostatin analogue eg. Octreotide
NB0 cardiac manifestations: pulmonary stenosis and tricuspid insufficiency
Risk factors for bowel ischaemia
Increased age
Emboli- AF, malignancy, infective endocarditis
CVD risk factors
Cocaine
Features of bowel ischaemia
Abdominal pain
Rectal bleeding
Diarrhoea
Fever
Bloods- elevated WCC, lactic acidosis
CT- investigation of choice
Acute mesenteric ischameia
Sudden onset acute abdominal pain
Out of keeping with physical exam findings
Urgent surgery required
Chronic mesenteric ischaemia
Intestinal angina
Colicky, intermittent, abdominal pain
Ischaemic colitis
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
Metoclopramide
D2 receptor antagonist
Used in management of nausea, GORD, gastroporeis, migraine
Adverse effects of metoclopramide
Extrapyramidal eg, oculogyric crisis, tardive dyskinesia, Parkinsonism
Hyperprolactinameia
Avoid in bowel obstruction, may be helpful in paralytic ileus
Peutz Jeghers syndrome
Hamartomatous polyps in small bowel
Pigmented lesions on lips, oral mucosa, face, palms, soles
Intestinal obstruction (intussusception)
GI bleeding
Adverse effects of PPI’s
Hyponatraemia, hypomagnesia
Osteoporosis- fracture risk
Colitis
Increased risk of c diff infection
Features of refeeding syndrome
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
Small bowel bacterial overgrowth syndrome
Diabetes Mellitus and scleroderma
Similar features to IBS
Hydrogen breath test for diagnosis
Correct underlying disorder and rifaximin (ABX)
Spontaneous bacterial peritonitis
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
Vitamin A
Retinol
Deficiency causes nighttime blindness
Vitamin B1
Thiamine
Deficiency- WKS, wet beri beri (heart)
Causes of deficiency- alcohol excess, malnutrition
Dry beri beri
Peripheral neuropathy
Wet beri beri
Dilated cardiomyopathy
Vitamin B3
Niacin
Deficiency causes pellagra- dermatitis, diarrhoea, dementia
Vitamin B6
Pyridoxine
Peripheral neuropathy and sideroblastic anaemia
Vitamin C
Ascorbic acid
Deficiency (scurvy) - gingivitis, loose teeth, poor wound healing, bleeding from gums, haematuria, epistaxis, general malaise, echymosis, easy bruising, Sjogrens, arthralgia
Zolinger Ellison syndrome
Syndrome caused by excess gastrin
Usually a duodenal or pancreatic tumour
MEN1
Diagnosis- fasting gastric levels
Features- gastric duodenal ulcers, diarrhoea, malabsorption
Ileostomy
Right iliac fossa
Spouted
Liquid
Colostomy
Often LHS
Flushed to skin (not spouted)
Solid output
Loop ileostomy
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)
End ileostomy
Following complete excision of colon
Reversal difficult
Loop colostomy
Reversible
Serves to defunction and decompress a distal segment of colon in obstructing cancers
Features of anal cancer
Perianal pain
Perianal bleeding
Palpable lesion
Faecal incontinence
Investigations for anal cancer
DRE, anoscopy with biopsy, check inguinal lymph nodes
Imaging
Check HIV status
Risk factors for an anal fissure
Constipation
IBD
STI- HIV, syphilis, herpes
Features of an anal fissure (fissure in ano)
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
Management of an acute anal fissure
Soften stool- dietary advice, bulk forming laxative
Lubricants before defeacation
Topical anaesthetic or analgesia
Management of a chronic anal fissure
Same measures as acute fissure
Topical GTN
IF GTN doesn’t work after 8 weeks- sphincterectomy or Botox
Pruritus ani
Itchy anus
Anal fistula
Usually due to a previous anorectal abscess
Rectal prolapse
Associated with childbirth and rectal intussception
Internal or external
Solitary rectal ulcer
Chronic straining and constipation
Causes of large bowel obstruction
Tumour
Volvulus
Diverticula disease
Adhesions
Hernias
Strictures
NB- not ileus as there is no obstruction in ileus, just a lack of peristalsis/movement
Clinical features of large bowel obstruction-+
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
Investigations for large bowel obstruction
Acute abdomen investigations, A-E assessment etc.
Abdominal x ray
CT scan
Management of large bowel obstruction
NBM, NG tube, IV fluids
Conservative management for 72 hours can be trialled if no perforation
Surgery (resection etc.) + IV antibiotics
Features of a perianal abscess
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
Treatment of a perianal abscess
Incision and drainage
Antibiotics if systemic symptoms
Thrombosed haemorrhoids
Significant pain and tender lump
Purple, oedematous perianal mass
If within 72 hours- excision. Otherwise, stool softeners, ice packs, analgesia
Features of a volvulus
Twisting of the colon around itself
Constipation
Abdominal pain and bloating
Nausea and vomiting
Management of volvulus
Refer to general surgeons
Sigmoid- rigid sigmoidoscopy with rectal tube insertion
Caecal- operative (right hemicolectomy sometimes required)
Complications of a laparoscopy
Anaesthetic risk
Vasovagal (bradycardia) in response to abdominal distension
Surgical emphysema
Injury to GI tract
Injury to blood vessels
Management of malignant surgical jaundice
Stent
Diagnosing surgical jaundice
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
Melanosis coli
Laxative abuse
Medication to avoid in bowel obstruction
Metoclopramide
Management of SBP
Take an ascitic culture prior to giving antibiotics
Usually treated with an IV cephalosporin such as cefotaxime
Hepatorenal syndrome
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.
What is ileus
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.
What is ileus
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.
Causes of ileus
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)
Features of ileus
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)
Management of ileus
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
What is a volvulus?
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)
Volvulus risk factors
Neuropsychiatric disorders (e.g., Parkinson’s)
Nursing home residents
Chronic constipation
High fibre diet
Pregnancy
Adhesions
Features of a volvulus
Akin to bowel obstruction, namely;
Vomiting (particularly green bilious vomiting)
Abdominal distention
Diffuse abdominal pain
Absolute constipation and lack of flatulence
Management of a volvulus
Conservative- same as obstruction eg. fluids, analgesia, NBM, NG tube etc.
Surgical- endoscopic resection for sigmoid volvulus (no peritonitis), or laparotomy/ colectomy etc.
Complications of stomas
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
Cholangiocarcinoma
Cancer arising from the bile ducts. Key risk factors include;
Primary sclerosing cholangitis
Liver flukes (a parasitic infection)
Features of cholangiocarcinoma
Obstructive jaundice
Unexplained weight loss
Right upper quadrant pain
Palpable gallbladder (swelling due to an obstruction in the duct distal to the gallbladder)
Hepatomegaly
Most appropriate analgesia following an abdominoperineal resection
Epidural
Investigation of choice in severe colitis
Flexible sigmoidoscopy, not colonoscopy
Differentials for an abdominal mass
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.
Hiatus hernia
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
Femoral Hernia
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)
Inguinal hernia
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)
Complications of an ileostomy
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
Investigation of choice for SBO
CT abdomen
Spigelian hernia
seen lateral to the umbilicus
