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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
Main causes of obstruction (1) small bowel (2) large bowel
(1) small bowel hernia, previous operations (2) large bowel tumors, twisting of caecum
26
Treatment in obstruction
Patient – V. dehydrated, distended abdomen Fluid resuscitation NG tube; Nil-by-mouth Analgesia Antiemetics Stop medication? Surgery – remove obstruction
27
Maldigestion
impaired breakdown of nutrients, lumenal phase
28
Malabsorption
defective mucosal uptake and transport of adequately digested nutrients. Selective or global. Malassimilation: encompasses both.
29
Malassimilation
Encompasses both maldigestion and malabsorption
30
Possible causes of issues with lumenal phase of absorption 1 - nutrient hydrolysis 2 - fat solubilization 3 - lumenal availability
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
Possible causes of issues with mucosal phase of absorption
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
Possible causes of issues with post- mucosal phase of absorption
Post-absorptive processing – lymphatic obstruction (lymphangectasia, neoplastic, TB)
33
Clinical features of malabsorption
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
Symptoms of B12 deficiency
Neurologic (B12) deficiency - Peripheral neuropathy - Ataxia (posterior column) - Psychosis, dementia
35
Microcytosis
iron deficiency - common in coeliac and suspect GI blood loss
36
Macrocytosis
B12, folate deficiency | common in colecial, alcohol
37
PARASYMPATHETIC NS
PARASYMPATHETIC NS Cholinergic drugs cause spasms; diarrhoea. Anticholinergic drugs: dry mouth; constipation.
38
SYMPATHETIC NS
SYMPATHETIC NS Dopaminergic drugs cause nausea, slow down transit Dopamine antagonists cause prokinetic (stimulate peristalsis); anti-emetic
39
Constipation treatments
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
Nausea and vomiting treatments
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
Antacid +/- alignates | - SE
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
Gastric acid production
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
PPI inhibitors - Examples - mechanism - indications - dose - SE
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
H2 receptor antagonists - Examples - mechanism - indications - dose - SE
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
Aminosalicylate drugs - Examples - mechanism - indications - dose - SE
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
Loperamide - Other similar examples - mechanism - indications - dose - SE
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
Codeine - Other similar examples - mechanism - indications - dose - SE
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
Co-phenotrope - Other similar examples - mechanism - indications - dose - SE
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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