PassMedicine Flashcards
what are the features of a surgical sieve
infective inflammatory vascular traumatic metabolic
what sort of pain does biliary colic present as
RUQ pain
features of biliary colic
gallstone lodged in bile duct
provoked after a fatty meal
how is acute cholecystitis as biliary colic differentiated
biliary colic - no fever and inflammatory markers are normal
what sort of pain does acute cholecystitis present as
RUQ pain
features of acute cholecystitis
inflammation/infection of gallbladder secondary to impacted gallstones
murphys sign positive
what is murphys sign
tests for gallbladder inflammation
arrest of inspiration on palpation of RUQ
what sort of pain does ascending cholangitis present as
RUQ pain
features of ascending cholangitis
bacterial infection of biliary tree
charcots triad
what is the most common predisposing factor in ascending cholangitis
gallstones
what is charcots triad
associated with ascending cholangitis
1 RUQ pain
2 fever
3 jaundice
acute pancreatitis presenting pain
epigastric pain
can radiate to the back
what is commonly associated with acute pancreatitis
1 alcohol
2 gallstones
peptic ulcer disease presenting pain
epigastric pain
history of peptic ulcer disease
history of NSAID use or alcohol excess
features of duodenal and gastric ulcers
duodenal>gastric
duodenal ulcers - pain relieved with eating
gastric ulcers - pain worsened with eating
what are common lower Gi problems of acute abdominal pain
1 appendicits
2 acute diverticulitis
3 intestinal obstruction
appendicitis presenting pain
RIF pain
features of RIF pain - appendicitis
pain initially in central abdomen before localising to RIF
anorexia common
rovsings sign
what is rosvings sign
sign of appendicitis
pain in RIF when LIF pressed
acute diverticulitis presenting pain
LLQ pain (colicky)
features of acute diverticulitis
diarrhoea (sometimes bloody)
fever, raised inflammatory markers, raised WCC
intestinal obstruction presenting pain
central pain
features of intestinal obstruction
history of malignancy (intraluminal obstruction) or operations (adhesions)
‘tinkling’ bowel sounds
common urological causes od acute abdominal pain
1 renal colic
2 acute pyelonephritis
3 urinary retention
renal colic presenting pain
loin pain radiating to groin
features of renal colic
visible or non-visible haematuria
acute pylonephritis presenting pain
loin pain
urinary retention presenting pain
suprapubic pain
features of urinary retention
obstruction of bladder outflow
men>women
history of benign prostatic hyperplasia in men
ectopic pregnancy pain
right or left iliac fossa pain
features of ectopic pregnancy
history of amenorrhoea
common vascular causes of abdominal pain
1 ruptured AAA
2 mesenteric ischaemia
rupture AAA pain
central abdominal pain radiating to back
features of ruptured AAA
if severe, sudden collapse
patients may go into shock (hypotension, tachycardia)
mesenteric ischaemia pain
central abdominal pain
features of mesenteric ischaemia
history of AF
diarrhoea/rectal bleeding
metabolic acidosis is often seen due to ‘dying’ tissue
what is the difference in pain between renal colic and acute pylonephritis
renal colic is colicky
acute pylonephritis is constant pain
coeliac disease is associated with what
anaemia
type 1 renal tubular acidosis is associated with what
renal stones
what causes coeliacs disease
sensitivity to gluten
repeated exposure leads to villous atrophy and results in malabsorption
what conditions are coeliacs disease associated with
dermatitis herpetiformis autoimmune disorders (T1DM, autoimmune hepatitis)
what HLA are associated with coeliacs
HLA-DQ2
HLA-B8
signs and symptoms in coeliacs
chronic/intermittant diarrhoea
persistant/unexplained GI symptoms (N+V)
fatigue
weight loss
a 70y/o man presents with anorexia, weight loss, painless jaundice
pancreatic cancer
a 65-year-old woman presents with jaundice, weight loss and passing clay-coloured stools. She also describes recurrent bouts of colicky RUQ abdominal pain. On examination a mass is palpable in the RUQ
Cholangiocarcinoma
a 20-year-old woman presents with recurrent episodes of abdominal pain associated with bloating. The pain is relieved on defecation. She normal passes 3 loose stools with mucous in the mornings
Irritable bowel syndrome
a 20-year-old man presents with a 3 week history of bloody diarrhoea associated with tenesmus
Ulcerative colitis
what antibodies are looked for in coeliac screen
tissue transglutaminase antibodies
a 40y/o man presents with severe pain on the right side of his back. this comes in waves. on examination he is restless with blood on the urine dipstick
renal colic
renal colic - presenting pain
loin pain radiating to groin
-colicky
what would be found in the urine with renal colic
visible or non-visible haematuria may be present
what are the two types of IBD
UC
CD
what are commonly found in both UC and CD
diarrhoea
arthritis
erythema nodosum
pyoderma gangrenosum (ulcers)
is blood diarrhoea associated with UC or CD
UC
PSC associated with UC or CD
UC
where does UC affect in the bowel
continuous disease
affects from rectum to ileocaecal valve
no inflammation beyond submucosa
where does CD affect in the bowel
skip lesions
anywhere from mouth to anus
inflammation in all layers
crypt abscesses - UC/CD
goblet cells - UC/CD
bowel obstruction - UC/CD
UC
CD
CD
which IBD is associated with loss of haustrations
UC
a 70/yo male presents with anorexia, weight loss, painless jaundice
pancreatic cancer
give two examples of PPIs
omeprazole
lansoprazole
what is the MOA for PPIs
reduce acid secretion in the stomach
irreversibly block H+/K+ ATPase of the gastric parietal cell
a 65y/o woman presents with jaundice, weight loss, passing of clay-coloured stools, she describes bouts of colicky RUQ pain, OE a mass is palpable in the RUQ
cholangiocarcinoma
what are the common features of a history of viral hepatitis
question may indicate foreign travel or IV drug use
nausea+vomiting
myalgia
RUQ pain
what are the common features of a history of biliary colic
RUQ pain
- colicky
- usually begins suddenly and subsides gradually
- often occurs after eating
who does biliary colic commonly affect
“female, forties, fat”
what are common features of a history of acute cholecystitis
RUQ pain
- constant
- more severe than biliary colic
what condition is murphys sign associated with
acute cholecystitis
what is charcots triad and what condition is it associated with
ascending cholangitis
1 fevers
2 RUQ pain
3 jaundice
what is reynolds pentad
associated with ascending cholangitits
1 fevers 2 RUQ pain 3 jaundice 4 hypotension 5 confusion
what are common features of a history of cholangiocarcinoma
persistant biliary colic symptoms weight loss courvoisiers sign sister mary joseph nodes virchows node
what is courvoisers sign
palpable mass in RUQ
what is sister mary joseph nodes
periumbilical lyphadenopathy
what are common features of a history of acute pancreatitis
severe epigastric pain
vomiting
tenderness
what is cullens sign
sign of acute pancreatitis
periumbilical discolouration
what is grey-turners sign
sign of acute pancreatitis
flank discolouration
what are common features of a history of pancreatic cancer
painless jaundice
weight loss
an overweight 45y/o woman presents with recurrent episodes of RUQ pain that is made worse by eating a fatty meal
biliary colic
a 50y/o man presents with epigastric pain relieved by eating
duodenal ulcer
painless jaundice
steatorrhoea
pancreatic cancer
common pancreatic tumours
adenoncarcinoma (head of pancreas) - 80%
risk factors for pancreatic cancer
age
smoking
diabetes
chronic pancreatitis
features of pancreatic caner
painless jaundice
patients usually present in a non-specific way (weight loss, epigastric pain)
loss of exocrine function (steatorrhoea)
A 20-year-old woman presents with recurrent episodes of abdominal pain associated with bloating. The pain is relieved on defecation. She normal passes 3 loose stools with mucous in the mornings
IBS
a 45y/o woman presents with fatigue and pruritus, blood tests show raised bilirubin, ALP, IgM
primary biliary cirrhosis/cholangitis
who is PBC commonly seen in
females
middle-aged
classic presentation of PBC
pruritus/itching
in a middle aged woman
clinical features of PBC
early: -asymptomatic -raised ALP later: -jaundice -hyperpigmentation (over pressure points) -xanthalasma/xanthamata
An obese 50-year-old woman presents with pain in the RUQ which radiates to the interscapular region. She is apyrexial and not jaundiced
biliary colic
what is metoclopramide
antiemetic
D2 receptor antagonist
side effects of metoclopramide
hyperprolactinaemia
parkinsonism
gallstones is common in which IBD
CD
A patient with a history of heartburn presents with odynophagia. There no weight loss, vomiting or anorexia
oesophagitis
what are 4 common causes of dysphagia
oesophageal cancer
oesophagitis
achalasia
myasthenia gravis
features of oesophageal cancer
dysphagia
- associated with weight loss, vomiting during eating
- PMH of barrett’s oesophagus, GORD, alcohol, smoking
features of oesophagitis
dysphagia
odynophagia
history of heart burn
features of achalasia
dysphagia of both liquids and solids from the start
heartburn
regurgitation
features of myasthenia gravis
dysphagia
extraocular muscles weakness/ptosis
A 70-year-old man with a history of benign prostatic hyperplasia presents with constant, severe suprapubic pai
urinary retention
a 40-year-old man presents with severe pain on the right side of his back. This comes in waves. On examination he is restless with blood+ on the urine dipstick
renal colic
a 35-year-old woman presents with pain on the right side of her back. This is constant and associated with fever and rigors
Acute pyelonephritis
what is common in acute pylonephritis
loin pain
fevers + rigors
vomiting
what is leukoplakia
oral mucosa white patches which do not run off
a premalignant lesions
what are aphthous ulcers
small shallow ulcers in the mouth
associated with CD, coeliacs
what is cheilitis (angular stomatitis)
inflammation and redness of the corners of the mouth
due to iron or riboflavin (B2) deficiency
what is gingivitis
gum hypertrophy and inflammation
associated with AML
what is glossitis
smooth, red, sore tongue
iron/b12/folate deficiency
what is macroglossia
tongue enlargement
associated with myxoedema (hypothyroidism) and acromegaly
how are causes of dysphagia classified
mechanical or obstructive
motility disorders
others
what are mechanical or obstructive causes of dysphagia
malignant strictures (oesophageal, gastric, pharyngeal cancer) benign strictures (oesophageal web, peptic stricture) extrinsic pressure (lung cancer, retrosternal goitre, LA enlargement) pharyngeal pouch
what are motility disorders which cause dysphagia
achalasia
diffuse oesophageal spasm
systemic sclerosis
bulbar palsy
what are other causes of dysphagia
oesophagitis
what questions must be asked in a dysphagia history and why
1 difficulty swallowing solids AND liquids from the start?
YES - motility disorder
NO - mechanical or obstructive (solids THEN liquids)
2 difficulty making swallowing movement?
YES - bulbar palsy
3 painful swallowing?
YES - malignancy or oesophageal ulcer
4 intermittant dysphagia or constant and worsening?
INTERMITTANT - oesophageal spasm
CONSTANT AND WORSENING - malignant strictures
5 neck bulge or gurgling on swallowing water?
YES - pharyngeal pouch
what is achalasia
failure of relaxation of LOS due to degeneration of myenteric plexus
what are features of achalasia
dysphagia (solids and liquids from the start)
regurgitation
what does “coffee grounds” when vomiting indicate
GI bleeding
what does food when vomiting indicate
gastric stasis or gastroenteritis
what does feculant (containing fecal matter) indicate
small BO
what does morning vomiting suggest
pregnancy
raised ICP
what does vomiting 1hr post food suggest
gastric stasis
what does vomiting which relieves pain suggest
peptic ulcer
what are the “attackers” in PUD
gastric acid
H pylori
what are the “defenders” in PUD
mucin secretion
bicarbonate secretion
what are the GI red flag symptoms
ALARM Symptoms
Anaemia (iron deficiency which suggests GI bleeding) Loss of weight Anorexia Recent onset or progressive symptoms Meleana or haematemesis Swallowing difficulty
which ulcers are more common duodenal or gastric ulcers
duodenal
what are the risk factors for duodenal ulcers
h. pylori
NSAIDs
steroids
what are the risk factors for gastric ulcers
h. pylori
NSAIDs
smoking
what are the symptoms in duodenal ulcers
epigastric pain
relieved by eating
what are the symptoms in gastric ulcers
epigastric pain
worsened by eating
how is diagnosis of duodenal ulcer made
upper GI endoscopy
what is triple therapy
for eradication of h. pylori
one week of a full does PPI, amoxicillin (1g) and clarithromycin (500mg)
complications of PUD
bleeding
perforation
malignancy
what are the DDx for dyspepsia
infection (h. pylori) -gastric or duodenal uclers inflammation -oesphagitis -gastritis -duodenitis malignancy (gastric)
when should someone with dyspepsia be referred for endoscopy
> 55yrs
or ALARM Symptoms
what is GORD
gastro-oesophageal reflux disease
reflux of acid with or without bile
what are the types of hiatus hernia
1 sliding HH (80%)
-GOJ moves in to the chest and LOS becomes incompetent leading to reflux of acid with or without bile (GORD)
2 rolling HH (20%)
-part of stomach herniates into the chest while the GOJ remains in the same position, as the GOJ remains intact, the LOS is not affected so there is no reflux
what is the first line investigation for a suspected hiatus hernia
barium swallow
