Secondary care notes Flashcards
What is a colloid fluid?
contains large molecules that cannot cross endothelium
What is a crystalloid fluid?
contains electrolytes that can cross endothelium
Name some crystalloid fluids
Hartmann’s
saline
dextrose
What fluid can’t you add stuff to?
Hartmann’s
What is prescribing 5% glucose essentially doing?
prescribing water
Indications for prescribing fluids
resuscitation
replacement of losses
routine maintenance
redistribution
How do you resuscitate a shocked patient?
500ml bolus of Hartmann’s/saline over 15mins
can repeat 4 times (2L)
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
What is a high output stoma?
> 1L/day
Which CXR can you comment on heart size on?
PA
Causes of pneumoperitoneum
perforated peptic ulcer
perforated diverticular disease
What is Rigler’s sign?
air on both sides of bowel wall
Causes of small bowel obstruction
adhesions
hernias
gallstone ileus
faecolith
bezoars
Sigmoid volvulus sign on AXR
coffee bean sign
Sigmoid volvulus treatment
flexible sigmoidoscopy
untwist + deflate
Caecal volvulus treatment
right hemicolectomy
Cause of dilated small bowel, dilated large bowel, drains and surgical clips in situ on CXR
post op ileus
Large bowel obstruction causes
colorectal cancer
diverticular disease - strictures
What does double contrast fluoroscopy mean?
air and contrast given
Apple core sign on fluoroscopy
colorectal cancer
Leadpipe colon sign cause and meaning
no bowel markings - smooth
ulcerative colitis
Is there air in the large and small intestines?
large bowel has air in it
small bowel does not
Define hernia
abnormal protrusion of a cavity’s contents through a defect in a wall
Why are platelets often low in cirrhosis?
due to portal hypertension causing splenomegaly
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?
CT
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
