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1
Q

What should you suspect in someone with atrial fibrillation and abdominal pain?

A

Mesenteric thrombosis

- could have small bowel ischaemia

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2
Q

Most common cause of splenomegaly & other causes?

A
  • Malaria (most common)

- other: thrombocytopenia, sickle cell (need special measures in surgery when administering anasethtic)

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3
Q

Aortic aneurysm

- typical patient

A

Male, fat, 60’s, back pain, had a collapse.

Intraperitoneal –> die
Retroperitoneal –> tamponade due to muscle + pressure

Treatment = clamp on aorta

BE careful when examining as may cause it to burst

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4
Q

Causes of small bowel obstruction

A
  • adhesions (may be from previous surgery)
  • hernia
  • Caecal cancer
  • Partial blockage - still get some gas through
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5
Q

Where does pain from perforation radiate to? What nerve is involved?

A

Shoulder tip pain

C4 phrenic nerve

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6
Q

What does an obstructed bowel sound like?

A

Initially some sounds then more, when dilates there are pinging sounds

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7
Q

What is a proctelectomy?

A

Removal of rectum and all/part of colon

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8
Q

What causes pseudomembranous colitis?

  • most likely organism
  • treatment?
A

Usually follows course of broad spectrum antibiotics

Characteristic macro and microscopic appearance

Caused by c. difficile

Treated with vancomycin or metronidazole

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9
Q

What is cyclosporin?

A

immunosuppressant - acts by inhibiting production and release of lymphokines therefore suppresses cell-mediated immune response.

Given prior to and as maintenance post transplant

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10
Q

What is TIPS?

A

Procedure that uses imaging guidance to connect the portal vein to the hepatic vein in the liver.

A stent is placed to keep the connection open and allow it to bring blood draining from the bowel back to the heart while avoiding the liver.

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11
Q

Terlipressin

A

Synthetic vasopressin analogue

Relative specificity for the splanchnic circulation where it causes vasoconstriction in these vessels with a reduction in portal pressure.

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12
Q

Positive AMA - what condition is likely?

A

Primary biliary cholangitis

PBC - M rule
IgM
anti-mitochondrial antibodies, M2 subtype
Middle aged females

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13
Q

What should you think if you see markedly elevated ALP?

A

Bile duct pathology

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14
Q

Sulphasalazine

  • What is it made up of?
  • SE
A

Ccombination of sulphapyridine (a sulphonamide) and 5-ASA

many side-effects are due to the sulphapyridine moiety: rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, lung fibrosis

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15
Q

Mesalazine

A

A delayed release form of 5-ASA
sulphapyridine side-effects seen in patients taking sulphasalazine are avoided.

mesalazine is still however associated with side-effects such as GI upset, headache, agranulocytosis, pancreatitis*, interstitial nephritis

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16
Q

IBD - which one can methotrexate be used in?

A

Crohns

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17
Q

Visceral pain

A

innervated by autonomic NS (sympathetic branch)

T6-12 and L1-2 through splanchnic nerves

Dull ache, poorly localized, nausea

stretching/traction, distention, inflammation, ischaemia, spasm

Areas and where they are felt:
foregut - epigastric area
midgut - umbilical area
hindgut - suprapubic area

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18
Q

Parietal pain

A

Innervated by somatic NS

severe, well localized, persistent

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19
Q

Somatic pain

  • where does it originate in?
  • what dermatomes are involved?
  • what sensation may stimulate this pain?
  • how would you describe this pain?
A

Originates in parietal peritoneum

T5- L2 dermatomes

mechanical, chemical, thermal stimulation

sharp constant pain

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20
Q

What stimulates gastric acid secretion?

A

Ach, Gastrin, histamine

21
Q

What inhibits gastric acid secretion?

A

Somatostatin, secretin, cholecystokinin

22
Q

Possible causes of pain in right hypochondriac region

A 
Biliary colic
ascending cholangitis
sub-phrenic abscess 
appendicitis
basal pneumonia
23
Q

Possible causes of pain in Epigastric region

A 
Pancreatitis
gastritis/duodenitis
AAA
perforated DU
MI
24
Q

Possible causes of pain in Left hypochondriac region

A

Ruptured spleen

25
Q

Main causes of obstruction

(1) small bowel
(2) large bowel

A

(1) small bowel
hernia, previous operations

(2) large bowel
tumors, twisting of caecum

26
Q

Treatment in obstruction

A

Patient – V. dehydrated, distended abdomen

Fluid resuscitation

NG tube; Nil-by-mouth

Analgesia

Antiemetics

Stop medication?

Surgery – remove obstruction

27
Q

Maldigestion

A

impaired breakdown of nutrients, lumenal phase

28
Q

Malabsorption

A

defective mucosal uptake and transport of adequately digested nutrients. Selective or global.
Malassimilation: encompasses both.

29
Q

Malassimilation

A

Encompasses both maldigestion and malabsorption

30
Q

Possible causes of issues with lumenal phase of absorption
1 - nutrient hydrolysis
2 - fat solubilization
3 - lumenal availability

A

Nutrient hydrolysis

  • Enzyme deficiency: pancreatic insufficiency

  • Enzyme inactivation: ZE syndrome

  • Inadequacy of mixing: rapid transit, surgical resection 


Fat Solubilization


  • Decreased bile salts: cholestasis, cirrhosis

  • Bile salt deconjugation: bacterial overgrowth
  • Bile salt loss: ileal disease or resection 


Lumenal availability


  • Bacterial consumption of nutrients (bacterial overgrowth): B12 deficiency

  • Decreased intrinsic factor (pernicious anemia): B12 deficiency
31
Q

Possible causes of issues with mucosal phase of absorption

A

Brush border hydrolysis: lactase deficiency (post gastroenteritis, alcohol, radiation)

Epithelial transport:

  • Reduced absorptive surface - resection
  • Damaged absorptive surface – coeliac disease, tropical sprue, Crohn’s disease, ischaemia
  • Infections – Giardia, SIBO

  • Infiltration – lymphoma, amyloid
32
Q

Possible causes of issues with post- mucosal phase of absorption

A

Post-absorptive processing – lymphatic obstruction (lymphangectasia, neoplastic, TB)

33
Q

Clinical features of malabsorption

A

Diarrhoea, Steatorrhoea (fat, bile salts)


Weight loss despite adequate intake

Bloating, distension, gas, cramps, borboygmi

Lethargy, malaise

Symptoms often mild non-specific

Diarrhoea and weight loss in normal diet!

Evidence of malnutrition

Skin

  • Angular cheilitis, glosssitis
  • Dermatitis herpetiformis
  • Oedema
34
Q

Symptoms of B12 deficiency

A

Neurologic (B12) deficiency

  • Peripheral neuropathy
  • Ataxia (posterior column)
  • Psychosis, dementia
35
Q

Microcytosis

A

iron deficiency - common in coeliac and suspect GI blood loss

36
Q

Macrocytosis

A

B12, folate deficiency

common in colecial, alcohol

37
Q

PARASYMPATHETIC NS

A

PARASYMPATHETIC NS
Cholinergic drugs cause spasms; diarrhoea.
Anticholinergic drugs: dry mouth; constipation.

38
Q

SYMPATHETIC NS

A

SYMPATHETIC NS
Dopaminergic drugs cause nausea, slow down transit
Dopamine antagonists cause prokinetic (stimulate peristalsis); anti-emetic

39
Q

Constipation treatments

A

Bulk-forming

  • Isphagul husk (fybogel, isogel)
  • Methylcellulose

Stimulant

  • Polyphenolics: bisacodyl, sodium picosulphate (Picolax)
  • Anthraquinones: senna, dantron

Faecal softeners

  • Arachis oil (From peanuts – ALLERGY?)
  • Liquid paraffin

Osmotic

  • Draw water into bowel and helps soften poo
  • Lactulose – synthetic dissacharide
  • Macrogols – polymers of ethylene glycol (Movicol)
  • Magnesium salts, phosphate salts
40
Q

Nausea and vomiting treatments

A

Phenothiazines
- Prochlorperazine 5-10mg, 8-hrly IM/IV

Dopamine antagonists

  • Metoclopramide 10mg 8-hrly oral/IV
  • Domperidone

Anti-histamines
- Cyclizine 50mg 8-hrly oral/IV

5HT3 antagonists
- Ondansetron/ granisetron

41
Q

Antacid +/- alignates

- SE

A

Aluminium hydroxide, magnesium carbonate, calcium carbonate

OTC – Rennies, Settlers, Tums
Combined with alginates – Peptac, Gaviscon

Indications: GORD,

MOA:

  • Neutralise gastric acid
  • Alginates – swell when mix with gastric juice, forming ball clot above gastric juice

Effective for mild symptoms – rarely achieve healing

SE: Mg → laxative; Al→ Constipating; Ca→ hyperCa,

42
Q

Gastric acid production

A

Gastric parietal cell produces protons and HCl through ATPase pump.

  • Histamine acts on H2 receptor (cAMP dependent pathway)
  • Acetylcholine acts on muscarinic M3 receptor
  • Gastrin acts on CCK2 receptor (Ca2+ dependent pathway)
  • H+K+ ATPase
43
Q

PPI inhibitors

  • Examples
  • mechanism
  • indications
  • dose
  • SE
A

Lansoprazole, pantoprazole, esomeprazole

MOA: Blocks final step in the H+ ion secretion by the H+/K+ ATPase 
enzyme system in gastric parietal cell 

- Most powerful acid suppressants

Indications 


  • GORD -1st line
  • Oesophagitis not responding to H2 antagonist

Administration 
– 20 mg once daily by mouth for 4 weeks 


SE 
– diarrhoea/GI upset but well tolerated long-term

44
Q

H2 receptor antagonists

  • Examples
  • mechanism
  • indications
  • dose
  • SE
A

Cimetidine, ranitidine, famotidine, nizatidine

MOA

  • reduced H2 receptor stimulation in gastric parietal cells
  • Decreased acid secretion, gastric volume and H+ concentrations

Heals mild oesophagitis in 70-80% patients with GORD

Indication: gastric, duodenal ulcers

Administration: 400mg 6hourly by mouth 4-8 weeks

SE:

  • Diarrhoea & GI upset, confusion
  • Cimetidine inhibits cytochrome P450 + has important interactions (warfarin, phenytoin, theophylline)
45
Q

Aminosalicylate drugs

  • Examples
  • mechanism
  • indications
  • dose
  • SE
A

Sulfasalazine, mesalazine, osalazine

MOA
- Unknown: 20 % absorbed but remainder goes to colon where colonic bacteria cleave the diazo bond to liberate 5-ASA molecule which remains in colon-> local anti-inflammatory effects

Indications

  • Flare-ups in UC & Crohn’s
  • Maintenance for UC
  • Sulfasalazine - rheumatoid arthritis

Administration
- Once daily by mouth (some given locally)

SE
- Sulfasalazine - more side effects than others 
– haematopoiesis depressed, photosensitivity, azoospermia, hypersensitvity

Monitoring and follow-up: FBC, LFTs

46
Q

Loperamide

  • Other similar examples
  • mechanism
  • indications
  • dose
  • SE
A

Other similar opioid drugs: codeine

MOA: Act on opioid receptors found in muscle lining of walls of intestines → reduces peristalsis increasing transit time allowing greater fluid absorption

Indication

  • Relief from short-term diarrhoea symptoms in adult/children up to 12 years
  • Relief from diarrhoea in adults with long-term diarrhoea
  • Treatment of short-term diarrhoea associated with IBS in adults

Administration: 2mg after each loose stool (max 16mg/d)

SE:

  • Dizziness, sleepiness, constipation, vomiting
  • Not to be used in toxic megacolon
47
Q

Codeine

  • Other similar examples
  • mechanism
  • indications
  • dose
  • SE
A

Other similar opioid drugs
Mild opioids: tramadol
Powerful: morphine

MOA

  • Opioid receptor agonsits
  • Reduced GI motility

Indications: acute diarrhoea

Administration: 30mg 3-4 times daily by mouth

SE: nausea, vomiting, dizziness, drowsiness, constipation

48
Q

Co-phenotrope

  • Other similar examples
  • mechanism
  • indications
  • dose
  • SE
A

Mixture of two drugs

  • Diphenoxylate hydrochloride 2.5 mg 

  • Atropine sulphate 25 μg
  • Lomotil is a 100:1 ratio of the two components

MOA

  • Diphenoxylate blocks nerve signals to intestinal 
muscles to increase transit time and reduce spasm 

  • Atropine is a muscarinic receptor antagonist

Indication: acute diarrhoea

Administration 
– 2 tablets every 6 hours until diarrhoea controlled

SE: dry mouth, constipation, drowsiness 


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