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Gastro/abdo > PDF notes > Flashcards

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1
Q

What does faecal urgency suggest?

A

rectal pathology (eg. cancer)

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2
Q

Key questions to ask in a diarrhoea history

A

describe stools (smell, float etc) travel, diet, contacts, bleeding, tenesmus, weight loss

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3
Q

Classic history of IBS?

A

Alternating diarrhoea and constipation

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4
Q

what does anorexia, weight loss, nocturnal diarrhoea suggest?

A

organic cause

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5
Q

Causes of bloody diarrhoea?

A

Vascular: ischaemic colitis
Infective: campylobacter, shigella, salmonella, E. coli, amoeba, pseudomembranous colitis
Inflammatory: UC Crohn’s
Neoplastic: CRC, polyps

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6
Q

Mucus in stools - causes?

A

IBS, CRC, polyps

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7
Q

Pus in stools - causes?

A

IBD, diverticulitis, abscess

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8
Q

Other diseases which cause diarrhoea (3)

A

Hyperthyroidism,
DM neuropathy,
Carcinoid syndrome

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9
Q

Coeliac serology (2)

A

anti-TTG or anti-endomysial Abs

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10
Q

What to look for in stool sample if infective suspected?

A

MCS, C. diff toxin

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11
Q

Bloods (other than coeliac serology)?

A
  • FBC: increased WCC, anaemia
  • U+E: reduced K+, dehydration
  • inc. ESR: IBD, Ca
  • inc. CRP: IBD, infection
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12
Q

Management of diarrhoea?

A

Treat cause
Oral or IV rehydration
Codeine phosphate or loperamide after each loose stool
Anti-emetic if associated with n/v: e.g. prochlorperazine
Abx (e.g. cipro) in infective diarrhoea can cause systemic illness

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13
Q

Describe C. difficile?

What does it release which causes problems?

A

Gram +ve spore forming anaerobe
Enterotoxins A & B
Commonest cause of Abx associated diarrhoea

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14
Q

What % of hops patients carry C. diff in their stool?

A

15-30% of hospital pts (cf. 3% of healthy adults)

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15
Q

antibiotics which predispose to C. diff? Other drugs?

A

clindamycin, cefs, augmentin, quinolones. Also PPIs

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16
Q

Clinical presentations of C. diff?

A 
Asymptomatic
 Mild diarrhoea
 Colitis w/o pseudomembranes
 Pseudomembranous colitis
 Fulminant colitis
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17
Q

How long after discontinuation of Abx can it occur?

A

May occur up to 2mo after

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18
Q

Presentation of pseudomembranous colitis?

A

fever & dehydration
abdo pain
Blood, mucus on PR
Yellow plaques on flexi sigmoidoscopy

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19
Q

Complications of pseudomembranous colitis?

A

Paralytic ileus
Toxic dilatation => perforation
Multi-organ failure

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20
Q

Investigations for suspected C. diff?

A
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21
Q

Criteria for severe C. diff?

A

WCC >15
Cr >50% above baseline
Temp >38.5
Clinical / radiological evidence of severe colitis

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22
Q

General management for C.diff?

A
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23
Q

Specific management for C.diff?

A

Metronidazole 400mg TDS PO x 10-14d

Vancomycin 125mg QDS PD x 10-14d

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24
Q

Managing severe C. diff?

A

Start with vanc 1st (can add metro IV)
Increase dose if no response.
Urgent colectomy if indicated

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25
Q

When may urgent colectomy be needed?

A
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26
Q

Treatment of C. diff if it recurs?

A
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27
Q

Definition of constipation

A

Infrequent BMs (</=3/wk) or passing BMs less often than normal or with difficulty, straining or pain.

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28
Q

Causes of pain on passing faeces?

A

Anal fissure

Proctalgia fugax

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29
Q

Neurological causes of constipation?

A

MS, myelopathy, cauda equina syndrome

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30
Q

Electrolyte/endocrine causes of constipation

A

low Ca, low K, low T4, uraemia

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31
Q

Obstructive causes of constipation

A
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32
Q

Other (general) causes of constipation:

A

Elderly
Diet / Dehydration IBS
Toxins/drugs

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33
Q

Drugs causes of constipation?

A
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34
Q

What management options (general areas) are there for constipation? When are they useful/contraindicated?

A

Conservative,
Bulking (not in obstruction/faecal impaction,
Osmotic (inc. enemas)
Stimulant (increase motility and secretion) - not in obstruction/acute colitis) (inc. suppository)
Softeners (good for painful anal conditions)

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35
Q

Examples of each type of laxative:

Conservative
Bulking
Osmotic
Osmotic enema
Stimulant
Stimulant suppository
Softener
A

Conservative: drink more, eat more fibre
Bulking: bran, fybogel, methyl cellulose
Osmotic: lactulose, MgSO4 (rapid), phosphate enema
Stimulant: Bisacodyl, senna, docusate sodium, sodium picosulphate (rapid), glycerol suppository
Softeners: liquid paraffin

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36
Q

Definition of IBS

A

Disorders of enhanced visceral perception

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37
Q

Core ROME criteria for IBS:

A

Abdo discomfort / pain for >/= 12wks which has 2 of:
Relieved by defecation
Change in stool frequency (either way)
Change in stool form: pellets, mucus

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38
Q

Extra ROME criteria (need 2 of:)

A
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39
Q

Exclusion criteria for IBS:

A
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40
Q

When to do a colonoscopy for long-standing constipation?

A

if >60yrs or any features of organic disease

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41
Q

Bloods in suspected IBS

A

FBC, ESR, LFT, coeliac serology, TSH

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42
Q

Management of IBS?

A

Exclusion diets can be tried
Bulking agents for constipation and diarrhoea (e.g.
fybogel).
Antispasmodics for colic/bloating (e.g. mebeverine)
Amitriptyline may be helpful
CBT

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43
Q

Causes of dysphagia

A 
oesophageal carcinoma
Rolling hiatus hernia
Oesophagitis (eg. GORD, candida)
tonsillitis
Diffuse oesophageal spasm
LNs/goitre
Achalasia
Bulbar/pseudobulbar palsy
SSc/CREST
MG
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44
Q

What does dysphagia of solids before liquids suggest? What about if both from the start?

A

Stricture

If both: motility disorder

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45
Q

Difficulty making the movement?

A

bulbar palsy

46
Q

Causes of neck bulging or gurgling?

A

Pharyngeal pouch

47
Q

If pain on swallowing?

A

Ca, oesophageal ulcer, oesoph. spasm (intermittent difficulty)

48
Q

5 signs to look for with dysphagia?

A
49
Q

Specific investigations (other than FBC, U&E, CXR, OGD)

A
50
Q

3 causes of achalasia (where LOS fails to relax)/

A

idiopathic, oesoph. Ca, Chagas’ disease (T. cruzi)

51
Q

Presentation of achalasia? (can lease to squamous cell Ca if chronic)

A
52
Q

Management of achalasia?

A
53
Q

How does pharyngeal pouch/Zenker’s diverticulum present? (3) How is it treated? (3)

A

Presents with regurgitation, halitosis, gurgling sounds.

Rx: excision, endoscopic stapling

54
Q

How does diffuse oesophageal spasm present?

A

Intermittent dysphagia ± chest pain

Ba swallow shows corkscrew oesophagus

55
Q

What does oesophageal manometry show in nutcracker oesophagus?

A
56
Q

Presentation of dyspepsia?

A

Non-specific symptoms, inc. epigastric pain, bloating, heartburn

57
Q

ALARMS symptoms in dyspepsia (6)

=> do OGD if any of these, or if >55 years

A
58
Q

Causes of dyspepsia

A
59
Q

Conservative Mx for dyspepsia (4 weeks)

A
60
Q

If no improvement in 4 weeks?

A

Test for H. pylori (breath or bloods)

61
Q

If no H. pylori detected?

A

PPI trial for weeks
OGD if no improvement
PPI can be used intermittently for symptom relief

62
Q

Management of proven GORD?

A
63
Q

Management if proven peptic ulcer:

A
64
Q

Which drugs do patients need to stop 2 weeks befor a C13 breath test for H. pylori?

A

cimetidine and PPIs

65
Q

2 management packages

A

PAC 500

66
Q

Peptic ucler disease - chronic causes?

A

H. pylori, NSAIDs, steroids, hypercalcaemia, Zollinger-Ellison (gastrinoma)

67
Q

Where are ulcers more common?

A

Duodenum (mainly the 1st part) - esp. in males

68
Q

Risk factors for peptic ulcers?

A

Smoking, H. pylori, delayed gastic emptying (GU)/increased (DU), blood group O

69
Q

Presentation + relieving factors of duodenal ulcers

A
70
Q

Presentation + relieving factors of gastric ulcers

A

Epigastric pain:

71
Q

Complications of PUD?

A

Haemorrhage
Perforation
Gastric Outflow Obstruction
Malignancy (H. pylori)

72
Q

Investigations in peptic ulcer disease?

A

Bloods: FBC, urea (increased in haemorrhage)

73
Q

Conservative management of PUD

A
74
Q

Medical management of PUD:

A
75
Q

Surgery for PUD - truncal vagotomy. What does this need to be combined with, and why?

A

decreased acid secretion but prevents pyloric sphincter relaxation, so this must be combined with pyloroplasty or gastroenterostomy. c.f selective which leaves the nerve supply to the pylorus intact.

76
Q

2 options for an antrectomy (with vagotomy)

A

Distal half of stomach removed + anastomosis:

77
Q

When is a Roux-en-Y bypass + subtotal gastrectomy perfomed?

A

Occasionally performed for Zollinger-Ellison syndrome

78
Q

Problems with ‘blind loop syndrome’?

A
79
Q

Physical complications

A
80
Q

Symptoms of dumping syndrome

A
81
Q

What is the pathophysiology of GORD?

A

LOS dysfunction

82
Q

7 risk factors for GORD?

A
83
Q

Oesophageal symptoms of GORD

A
84
Q

Other (extra-oesophageal) symptoms of GORD?

A
85
Q

Complications of GORD:

A
86
Q

Differentials for GORD

A

Oesophagitis

87
Q

When to do an OGD in suspected GORD?

A
88
Q

Other tests to do?

A
  • Ba swallow: hiatus hernia, dysmotility

- 24h pH testing ± manometry (pH 4hrs)

89
Q

Conservative management of GORD?

A
90
Q

Medical management of OGD?

A
91
Q

When is Nissen fundoplification (laparoscopic) indicated?

A

When pt. has all 3 of:

92
Q

What type of hiatus hernia is more common? Which type is more assoc’d with GORD?

A

Sliding (G-O junction slides up into chest). -80%, more assoc’ with GORD
Rolling is less common (15% -> can result in strangulation so ALWAYS repair even if asymptomatic)

93
Q

4 key investigations in hiatus hernia

A
94
Q

What is Boerhaave’s Syndrome?

A
95
Q

Infectious causes of rectal bleeding? (5)

A

Campylobacter, shigella, E. coli, C. diff, amoebic dysentery

96
Q

Angio causes of PR bleeding?

A
97
Q

Upper GI bleeding - history

A
98
Q

Examination signs of upper GI bleeding?

A
99
Q

Common causes of upper GI bleeding?

A
100
Q

Bleed prevention in oesophageal varices?

A
101
Q

Normal bilirubin level?

When is jaundice visible?

A

3-17uM

Jaundice visible @ 50uM (3 x ULN)

102
Q

What is the normal metabolism of Hb -> bile?

A

Hb => unconjugated BR by splenic macrophages

uBR => cBR by BR-UDP-glucuronyl transferase in liver

103
Q

What happens when cBR is secreted into the bile?

A

Secreted in bile then cBR

104
Q

Obstructive causes of jaundice?

A
105
Q

Pre-hepatic causes of jaundice (2)

A
106
Q

Causes of raised UNconjugated BR in blood?

A

reduced BR Uptake

107
Q

Causes of raised conjugated BR in blood?

A

Hepatocellular Dysfunction

108
Q

Drugs which cause hepatitis?

A
109
Q

Drugs which cause cholestasis?

A

Fluclox (may be weeks after Rx)

110
Q

Gilbert’s disease. What is it, presentation, Dx?

A
111
Q

What is Crigler-Najjar?

How is it managed?

A

Rare auto rec total UDP-GT deficiency Severe neonatal jaundice and kernicterus
Rx: liver Tx

112
Q

Urine in post-hepatic jaundice?

in pre-hepatic?

A 
Greatly increased BR (more than in hepatic)
No urobilinogen (which would be increased in hepatic)

In pre-hepatic, urin has no bilirubin but increased urobilinogen, possibly Hb

Gastro/abdo (2 decks)

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