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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
When may urgent colectomy be needed?
26
Treatment of C. diff if it recurs?
27
Definition of constipation
Infrequent BMs (
28
Causes of pain on passing faeces?
Anal fissure | Proctalgia fugax
29
Neurological causes of constipation?
MS, myelopathy, cauda equina syndrome
30
Electrolyte/endocrine causes of constipation
low Ca, low K, low T4, uraemia
31
Obstructive causes of constipation
32
Other (general) causes of constipation:
Elderly Diet / Dehydration IBS Toxins/drugs
33
Drugs causes of constipation?
34
What management options (general areas) are there for constipation? When are they useful/contraindicated?
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)
35
Examples of each type of laxative: ``` Conservative Bulking Osmotic Osmotic enema Stimulant Stimulant suppository Softener ```
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
36
Definition of IBS
Disorders of enhanced visceral perception
37
Core ROME criteria for IBS:
Abdo discomfort / pain for >/= 12wks which has 2 of: Relieved by defecation Change in stool frequency (either way) Change in stool form: pellets, mucus
38
Extra ROME criteria (need 2 of:)
39
Exclusion criteria for IBS:
40
When to do a colonoscopy for long-standing constipation?
if >60yrs or any features of organic disease
41
Bloods in suspected IBS
FBC, ESR, LFT, coeliac serology, TSH
42
Management of IBS?
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
43
Causes of dysphagia
``` oesophageal carcinoma Rolling hiatus hernia Oesophagitis (eg. GORD, candida) tonsillitis Diffuse oesophageal spasm LNs/goitre Achalasia Bulbar/pseudobulbar palsy SSc/CREST MG ```
44
What does dysphagia of solids before liquids suggest? What about if both from the start?
Stricture | If both: motility disorder
45
Difficulty making the movement?
bulbar palsy
46
Causes of neck bulging or gurgling?
Pharyngeal pouch
47
If pain on swallowing?
Ca, oesophageal ulcer, oesoph. spasm (intermittent difficulty)
48
5 signs to look for with dysphagia?
49
Specific investigations (other than FBC, U&E, CXR, OGD)
50
3 causes of achalasia (where LOS fails to relax)/
idiopathic, oesoph. Ca, Chagas' disease (T. cruzi)
51
Presentation of achalasia? (can lease to squamous cell Ca if chronic)
52
Management of achalasia?
53
How does pharyngeal pouch/Zenker's diverticulum present? (3) How is it treated? (3)
Presents with regurgitation, halitosis, gurgling sounds. | Rx: excision, endoscopic stapling
54
How does diffuse oesophageal spasm present?
Intermittent dysphagia ± chest pain | Ba swallow shows corkscrew oesophagus
55
What does oesophageal manometry show in nutcracker oesophagus?
56
Presentation of dyspepsia?
Non-specific symptoms, inc. epigastric pain, bloating, heartburn
57
ALARMS symptoms in dyspepsia (6) => do OGD if any of these, or if >55 years
58
Causes of dyspepsia
59
Conservative Mx for dyspepsia (4 weeks)
60
If no improvement in 4 weeks?
Test for H. pylori (breath or bloods)
61
If no H. pylori detected?
PPI trial for weeks OGD if no improvement PPI can be used intermittently for symptom relief
62
Management of proven GORD?
63
Management if proven peptic ulcer:
64
Which drugs do patients need to stop 2 weeks befor a C13 breath test for H. pylori?
cimetidine and PPIs
65
2 management packages
PAC 500
66
Peptic ucler disease - chronic causes?
H. pylori, NSAIDs, steroids, hypercalcaemia, Zollinger-Ellison (gastrinoma)
67
Where are ulcers more common?
Duodenum (mainly the 1st part) - esp. in males
68
Risk factors for peptic ulcers?
Smoking, H. pylori, delayed gastic emptying (GU)/increased (DU), blood group O
69
Presentation + relieving factors of duodenal ulcers
70
Presentation + relieving factors of gastric ulcers
Epigastric pain:
71
Complications of PUD?
Haemorrhage Perforation Gastric Outflow Obstruction Malignancy (H. pylori)
72
Investigations in peptic ulcer disease?
Bloods: FBC, urea (increased in haemorrhage)
73
Conservative management of PUD
74
Medical management of PUD:
75
Surgery for PUD - truncal vagotomy. What does this need to be combined with, and why?
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
2 options for an antrectomy (with vagotomy)
Distal half of stomach removed + anastomosis:
77
When is a Roux-en-Y bypass + subtotal gastrectomy perfomed?
Occasionally performed for Zollinger-Ellison syndrome
78
Problems with 'blind loop syndrome'?
79
Physical complications
80
Symptoms of dumping syndrome
81
What is the pathophysiology of GORD?
LOS dysfunction
82
7 risk factors for GORD?
83
Oesophageal symptoms of GORD
84
Other (extra-oesophageal) symptoms of GORD?
85
Complications of GORD:
86
Differentials for GORD
Oesophagitis
87
When to do an OGD in suspected GORD?
88
Other tests to do?
- Ba swallow: hiatus hernia, dysmotility | - 24h pH testing ± manometry (pH 4hrs)
89
Conservative management of GORD?
90
Medical management of OGD?
91
When is Nissen fundoplification (laparoscopic) indicated?
When pt. has *all 3* of:
92
What type of hiatus hernia is more common? Which type is more assoc'd with GORD?
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
4 key investigations in hiatus hernia
94
What is Boerhaave’s Syndrome?
95
Infectious causes of rectal bleeding? (5)
Campylobacter, shigella, E. coli, C. diff, amoebic dysentery
96
Angio causes of PR bleeding?
97
Upper GI bleeding - history
98
Examination signs of upper GI bleeding?
99
Common causes of upper GI bleeding?
100
Bleed prevention in oesophageal varices?
101
Normal bilirubin level? | When is jaundice visible?
3-17uM | Jaundice visible @ 50uM (3 x ULN)
102
What is the normal metabolism of Hb -> bile?
Hb => unconjugated BR by splenic macrophages | uBR => cBR by BR-UDP-glucuronyl transferase in liver
103
What happens when cBR is secreted into the bile?
Secreted in bile then cBR
104
Obstructive causes of jaundice?
105
Pre-hepatic causes of jaundice (2)
106
Causes of raised UNconjugated BR in blood?
reduced BR Uptake
107
Causes of raised conjugated BR in blood?
Hepatocellular Dysfunction
108
Drugs which cause hepatitis?
109
Drugs which cause cholestasis?
Fluclox (may be weeks after Rx)
110
Gilbert's disease. What is it, presentation, Dx?
111
What is Crigler-Najjar? | How is it managed?
Rare auto rec total UDP-GT deficiency Severe neonatal jaundice and kernicterus Rx: liver Tx
112
Urine in post-hepatic jaundice? in pre-hepatic?
``` 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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