Secondary care notes Flashcards by Jasmine Henson

What is a colloid fluid?

contains large molecules that cannot cross endothelium

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What is a crystalloid fluid?

contains electrolytes that can cross endothelium

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Name some crystalloid fluids

Hartmann’s
saline
dextrose

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What fluid can’t you add stuff to?

Hartmann’s

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What is prescribing 5% glucose essentially doing?

prescribing water

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Indications for prescribing fluids

resuscitation
replacement of losses
routine maintenance
redistribution

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How do you resuscitate a shocked patient?

500ml bolus of Hartmann’s/saline over 15mins
can repeat 4 times (2L)

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How are routine maintenance fluid prescriptions calculated?

calculate daily fluid and electrolyte requirements

fluid 25-30ml/kg/day
sodium 1-1.5 mmol/kg/day
potassium 1mmol/kg/day
glucose 50-100g/day

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What is a high output stoma?

> 1L/day

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Which CXR can you comment on heart size on?

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Causes of pneumoperitoneum

perforated peptic ulcer
perforated diverticular disease

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What is Rigler’s sign?

air on both sides of bowel wall

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Causes of small bowel obstruction

adhesions
hernias
gallstone ileus
faecolith
bezoars

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Sigmoid volvulus sign on AXR

coffee bean sign

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Sigmoid volvulus treatment

flexible sigmoidoscopy
untwist + deflate

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Caecal volvulus treatment

right hemicolectomy

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Cause of dilated small bowel, dilated large bowel, drains and surgical clips in situ on CXR

post op ileus

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Large bowel obstruction causes

colorectal cancer
diverticular disease - strictures

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What does double contrast fluoroscopy mean?

air and contrast given

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Apple core sign on fluoroscopy

colorectal cancer

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Leadpipe colon sign cause and meaning

no bowel markings - smooth
ulcerative colitis

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Is there air in the large and small intestines?

large bowel has air in it
small bowel does not

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Define hernia

abnormal protrusion of a cavity’s contents through a defect in a wall

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Why are platelets often low in cirrhosis?

due to portal hypertension causing splenomegaly

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Causes of hepatic LFTs

fatty liver (alcohol-related, NAFLD) viral hepatitis autoimmune hepatitis drug-induced liver injury

Causes of cholestatic LFTs

PBC PSC biliary obstruction (stones, stricture, Ca pancreas, cholangiocarcinoma) hepatic congestion drug-induced liver injury

What does an AST:ALT ratio of 2:1 suggest?

alcoholic liver disease

What are some commercial serum fibrosis marker tests?

ELF test

What is AST/ALT >1 diagnostic of?

cirrhosis (AST/ALT>0.8 more sensitive in NAFLD)

What is the other name for fibro scan?

transient elastography

What factors can affect transient elastography scores?

disease aetiology obesity recent heavy meal recent alcohol binge operator experience probe size

Why do we need liver biopsy in NAFLD?

confirm diagnosis confirm advanced fibrosis diagnose NASH exclude other cofactors

Which bilirubin will be high in Gilbert's?

unconjugated

What would an isolated raised ALP raise suspicion of?

bone disease - ?low vit D

Autoantibody present in autoimmune hepatitis

anti-smooth muscle

What immunoglobulin is raised in autoimmune hepatitis?

IgG

What is the best scan for imaging the pancreas?

Are CT scans good for gallstones?

no cholesterol stones will not show

What is the best scan to visualise CBD stones?

MRI/MRCP

How does PSC look on MRCP?

multiple narrowings (strictures) in biliary tree with dilatation behind it

What is ERCP used for?

therapeutic, not diagnostic removal of CBD stones decompression of biliary obstruction

What is the most sensitive test for gallstones?

endoscopic ultrasound

What is the most sensitive test for early chronic pancreatitis and small pancreatic tumours?

endoscopic ultrasound

Painless obstructive jaundice and weight loss?

pancreatic cancer/cholangiocarcinoma

Origin of cystic artery

right hepatic artery (in 80% of people)

What artery supplies the gallbladder?

cystic artery

Cholelithiasis meaning

stones in gallbladder

Choledocholithiasis meaning

stones in CBD

Biliary microlithiasis meaning

gallstones<3mm diameter

What cells secrete CCK?

I cells of duodenum

What drains a gallbladder empyema?

cholecystostomy

What activates pancreatic enzymes?

trypsin

What causes a high GGT but no obstructive jaundice?

alcohol

Radiographic sign of head of pancreas cancer

double duct sign dilatation of the common bile duct and pancreatic duct

What is Courvoisier's Law?

if gallbladder is palpable in a jaundiced patient, it is unlikely to be due to gallstones, because stones would have given rise to chronic inflammation and subsequently fibrosis of gallbladder therefore, rendering it incapable of dilatation

What are the normal maximum diameters of the small bowel, large bowel and caecum?

small bowel = 3cm large bowel = 6cm caecum = 9cm

Signs of gallstone ileus

pneumobilia gallstones small bowel dilatation

What is a cholecystoduodenal fistula?

tract between gallbladder and duodenum

What is an enterotomy?

incision in small bowel

What is Mirizzi syndrome?

common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder

What is Bouveret syndrome?

a rare form of gallstone ileus secondary to an acquired fistula between the gallbladder and either the duodenum or stomach. Through the fistula, a gallstone may enter the enteric system and cause a gastric outlet obstruction

How does gastric outlet obstruction present?

vomiting hypochloric hypokaleemic metabolic alkalosis

Why is common bile duct hard to see on USS?

CBD enters duodenum posteriorly

What do pancreas delta cells produce?

somatostatin

What do pancreas alpha cells produce?

glucagon

What do pancreas beta cells produce?

insulin

Pancreatitis causes

alcohol gallstones idiopathic drugs autoimmune (IgG4) scorpions ERCP

Can pancreatitis patients eat and drink?

yes

What is a Hartmann's operation?

a type of colectomy that removes part of the colon and sometimes rectum (proctosigmoidectomy). The remaining rectum is sealed, creating what is known as Hartmann's pouch. The remaining colon is redirected to a colostomy. It can be reversed later

What is a subtotal colectomy?

leaves small amount of rectum, all colon removed

What surgery is done if there is a carcinoid tumour of the appendix?

right hemicolectomy

What surgery is done as an emergency if there is a cancer in sigmoid colon causing an obstruction?

defunctioning ileostomy then plan the definitive surgery

Describe stoma examination

look inside stoma bag remove bag look at surrounding skin look at stoma stump look for peristalsis poke finger in with lube look at finger put a new bag on

What does having a stoma bag that is much wider than the stump cause?

contact dermatitis

When is NAC definitely given for paracetamol overdose?

after 8 hours

If a paracetamol overdose was taken 4-8 hours ago, how do you decide on treatment?

paracetamol normogram above line = treat with NAC

What do you give if a paracetamol overdose was taken <1 hour ago?

activated charcoal

What criteria can be used to decide if a liver transplant should be offered?

King's college criteria Child-Pugh