Presentations Flashcards
HAEMATEMESIS causes?
- oesophageal varices (cause of these?)
- gastric ulcers (erosion into what vessels?) (what causes them?)
- mallory-weiss tear
- oesophagitis (cause?)
- gastritis
- gastric malignancy
- meckel’s diverticulum
- vascular malformations (eg dieulafoy lesion - what is this?)
HAEMATEMESIS what things do we want to get from the history?
- bleeding: timing, freq, volume
- dyspepsia? dysphasia? odynophagia?
- PMH
- smoking? alcohol?
- use of steroids, NSAIDs, anticoags, bisphophonates
HAEMATEMESIS what do we specifically want to do on examination?
epigastric tenderness
peritonism
any features suggestive of potential underlying cause
HAEMATEMESIS what investigations?
- bloods - fbc, u&es, lfts, clotting, group & save
- vbg
- OGD (within 12hrs of acute haematemesis or asap if unstable)
- erect CXR (why?)
- CT abdo w IV contrast (why?)
HAEMATEMESIS management?
- ABCDE
- 2 large bore IV cannulas for fluid rests
- crossmatch blood if needed !!
- angio embolisation for actively bleeding patient (what artery? when?)
DYSPHAGIA mechanical causes?
- oesophageal/gastric malignancy
- benign oesophageal strictures
- extrinsic compression
- pharyngeal pouch
- foreign body (most common in what age?)
- oesophageal web
DYSPHAGIA neuromuscular causes?
- post stroke
- achalasia (what is this?)
- diffuse oesophageal spasm
- myasthenia gravis
- myotonic dystrophy
DYSPHAGIA what things do we want to get from the history?
- difficulty initiating swallowing action?
- do u cough after swallowing?
- do u have to swallow a few times to get food to pass throat?
- differentiate dysphagia from odynophagia!! (why?)
- also: presence of regurg, sensation of food becoming ‘stuck’, hoarse voice, weight loss, referred ear or neck pain
DYSPHAGIA on examination?
- look in mouth for oral pathologies
- examine for any GI or resp disease that may impact swallow
- assess nutritional status
DYSPHAGIA investigations?
- endoscopy +- biopsy (to exclude what?)
- bloods - routine inc fbc & lfts
- motility disorder suspected? manometry & 24 pH studies
- pouch suspected? barium swallow
DYSPHAGIA cancer referral pathway
urgent upper GI endoscopy within 2 weeks to assess for oesophageal cancer in ppl:
- w dysphagia
- age >55yrs w weight loss + upper abdo pain/reflux/dyspepsia
(non urgent referral is recommended w haematemsis or >55yrs w treatment resistant dyspepsia or upper abdo pain)
DYSPHAGIA management?
- treat underlying cause
- malignancy treatment = surgical excision or palliatiom (w chemo or stents)
- motility disorders = underlying cause treated & referral for swallowing therapy
- no cause identified? referral to SALT & dieticians
BOWEL OB explain the pathology
- bowel ob -> mechanical blockage of bowel.
- when bowel has become occluded gross dilatation of the proximal limb of the bowel occurs leading to inc peristalsis of the bowel. this leads to the secretion of large volumes of electrolyte rich fluid into the bowel (termed?). therefore, urgent fluid resus & careful fluid balance is required.
BOWEL OB what is a closed loop obstruction?
2 obstructions which leave a part of bowel in the middle at risk of ischaemia or perforation as it’ll continue to distend
- give 2 examples
BOWEL OB small bowel ob most common causes?
adhesions & hernia
BOWEL OB large bowel ob most common causes?
malignancy, diverticula disease & volvulus
BOWEL OB causes based on the following locations: intraluminal, mural (bowel wall) & extramural.
- intraluminal - gallstone ileus, ingested foreign body, faecal impaction
- mural - cancer, inflammatory strictures, intussusception, diverticula strictures, meckel’s diverticulum, lymphoma
- extramural - hernias, adhesions, peritoneal mets, volvulus
*** what one is especially in ppl w crohns? what about in children?
BOWEL OB cardinal features?
- abdo pain - what type? 2 ° to what?
- vomiting - when does it occur in proximal vs distal obs?
- abdo distension
- absolute constipation - what is this? when does it occur in proximal vs distal obs?
BOWEL OB on examination?
- may show evidence of underlying cause eg ?? or abdo distension
- asses patients fluid status !! why - what can occur in bowel ob?
- palpate for focal focal tenderness (inc guarding & rebound tenderness - only occur w ischaemia)
- percussion - tympanic sound
- auscultation - tinkling bowel sounds
BOWEL OB differential diagnoses?
- pseudo - obstruction
- paralytic ileus
- toxic megacolon
- constipation
what are these!?
BOWEL OB what lab tests?
- bloods - fbc, crp, u&es, lfts, g&s
- vbg - why?
BOWEL OB imaging?
- CT AP w IV contrast -> what 4 reasons are CTs preferred over AXRs?
- AXR sometimes still used - what does it show in SBO? what does it show in LBO? **think! size of bowel? location? what lines visible?
- erect CXR - air under diaphragm in perforation
- fluoroscopy w gastrograffin in SBO due to adhesions from previous surgery - what does it predict?
BOWEL OB definitive management?
- depends on aetiology & whether it’s been complicated by ischaemia, perforation and/or peritonism
- urgent fluid resus
- careful attention to fluid balance
- catheter
BOWEL OB conservation management?
in the absence of signs of ischaemia or strangulation ‘drip & suck’ management:
- NBM & insert NG tube to decompress bowel (suck)
- IV fluids to correct electrolyte disturbances (drip)
- catheter & fluid balance
- analgesia prn w anti emetics
BOWEL OB surgical management?
surgery indicated in patients w:
- suspicion of intestinal ischaemia or closed loop bowel ob
- case that requires surgical correction eg??
- if patients fail to improve w conservation measures (> ? hrs)
- normally laparotomy. if bowel resection required anastomoses is often not possible so stoma needed
BOWEL OB complications?
- bowel ischaemia
- bowel perf … peritonitis
- dehydration & renal impairment
GI PERF causes?
- diverticulitis
- PUD
- GI malignancy - mainly where?
- iatrogenic eg?
- trauma
- foreign body eg?
- appendicitis
- mesenteric ischaemia
- obstructing lesions eg? then leads to what etc??
- severe colitis eg crohns. also inc toxic megacolon or UC
- xs vomiting (? syndrome) leading to oesophageal perf
GI PERF clinical features?
- pain - nature of it?
- systemically unwell .. associated malaise, vomiting & lethargy
GI PERF on examination?
- patients look unwell & often have features of sepsis
- features of peritonism - may be localised or generalised (rigid abdo) …. generalised implies diffuse contamination of abdo & patient v unwell
GI PERF thoracic perf presentation & examination?
eg oesophageal rupture
- present w pain (chest/neck/radiating to back/worsening on inspiration)
- associated vomiting & resp symptoms
- auscultation & percussion may reveal signs of pleural effusion w the potential for palpable crepitus
GI PERF lab tests?
- bloods - fbc, u&es, lfts, crp, clotting & g&s
* raised wcc & crp common + mildly elevated amylase
GI PERF imaging?
- CT is gold standard - what does it show?
- eCXR & AXR used less now
GI PERF management?
- broad spectrum Abx
- NBM
- NG tube considered
- IV fluid resus
- analgesia
…. following this standard initial approach management becomes highly individualised
GI PERF surgical intervention key features?
key features:
- identification of underlying cause
- appropriate management of perf
- thorough washout
GI PERF when are patients given conservation treatment rather than surgical?
- if they have localised diverticula perf w only localised peritonitis & tenderness & no evidence of generalised contamination on imaging
- patients w sealed upper GI perf on CT w/o generalised peritonism
- elderly, frail patients w extensive comorbidities who are unlikely to survive surgery
MALAENA overview?
- black tarry stools
- due to upper GI bleed
- tarry colour & offensive smell
MALAENA causes?
- PUD ( should be suspected as the cause of malaena in ppl w active pud, nsaid/steroid use, prev dyspepsia like symptoms, h pylori +ve). what artery is most commonly eroded into?
- variceal bleeds. varices - dilation of porto-systemic anastomoses due to portal htn due to alcoholic liver disease
- upper GI malignancy. where is most common? ask about red flags!!
- less common causes: gastritis, oesophagitis, mallory weiss tear, meckel’s diverticulum, vascular malformations eg dieulafoy lesion
MALAENA what to get from a history?
- colour & texture of stool - ??
- associated symptoms - ??
- PMH - ??
- drug Hx - ??
do a DRE & abdo exam (to assess for what 4 things?)
MALAENA investigations?
- bloods - fbc, u&es, lfts, clotting, g&s, cross match 4 units for those w significant malaena.
- drop in hb & rise in urea:creatinine indicates bleed where?
- abg - why?
- OGD - definitive investigation
- CT abdo w IV contrast (triple phase - what is this?)good for active bleeding
MALAENA management?
- ABCDE
- OGD for investigation & management:
~ PUD adrenaline & cauterisation of bleed. high dose PPI
~ oesophageal varices endoscopic banding, prophylactic abx w somatostatin analogues (why?), sengstaken-blakemore tube (when? how does it work?)
~ upper GI malignancy biopsies taken & long term surgical & ontological management put in place - blood transfusion to haemodynamically unstable/ hb <70g/L patients
- correct any deranged coagulation (how?)
RECTAL BLEEDING common causes?
- diverticulosis (inc incidence w age) - what are diverticula? commonly found where? diverticula disease bleeds = painless. diverticulitis bleeds = painful -why?
- haemorrhoids - what are they? blood on surface of stool or pan rather than mixed in. they can thrombose - v v painful
- malignancy - colorectal cancer. ask about red flags!!
RECTAL BLEEDING what to get from the history?
- nature of bleeding inc duration, colour, relation to stool & defecation
- associated symptoms inc pain (especially association w defaecation), haematemesis, PR mucus or prev episodes
- FHx of bowel ca or IBD
RECTAL BLEEDING on examination?
- abdo exam for localised tenderness or palpable masses
- DRE
RECTAL BLEEDING investigations?
- bloods - fbc, u&es, lfts, clotting, g&s
- stool culture - to exclude what?
- CT angiogram to identify source of bleeding (patient must be haemodynamically stable!!)
- therapeutic intervention - embolisation
stable bleed patients only: - flexible sigmoidoscopy (or colonoscopy) to exclude what??
- nothing found? OGD
RECTAL BLEEDING management
~ 95% cases settle spontaneously
- unstable bleed? A-E, urgent resus w IV fluids & blood products until stabilised
- hb < 70 ? transfusion of packed RBCs. patients on anti coag should have it reversed urgently
- endoscopic haemostasis methods inc injection (?), contact & non contact thermal devices (?) & mechanical therapies (?)
- arterial embolisation for those w incentivised bleeding point of sufficient size on angiogram
RECTAL BLEEDING surgical management?
rarely required but considered in patients w ongoing lower GI bleed w instability (or requiring continued transfusion) where endoscopic and radiographic treatment has failed
