The Digestive System - Small Bowel/ Nutrition, Pancreas and GI Bleeding Flashcards
1
Q
Developmental diseases in small bowel
A
Atresia
Stenosis
Duplications
Meckel diverticulum
2
Q
Atresia of small bowel
A
Complete occlusion of intestinal lumen or lack of continuity of ends
3
Q
Stenosis of small bowel
A
Stricture of the intestinal lumen secondary to incomplete intraluminal diaphragm
3
Q
Stenosis of small bowel
A
Stricture of the intestinal lumen secondary to incomplete intraluminal diaphragm
4
Q
Duplications of small bowel
A
Enteric cysts that may communicate w/ the intestinal lumen (most common in ileum)
May cause gastric mucosa and cause peptic ulcer
5
Q
Meckel divertiuclum
A
Partial persistence of the vitelline duct, 60-100cm before the ileocaecal valve, w/ all layers of intestinal or gastric mucosa
6
Q
Development issues of large intestines
A
Abnormal positioning of colon in Abdominal cavity e.g. caecum in LUQ
May give rise to volvulus
7
Q
Pathophys of coeliac disease
A
Reaction to gliadin
Gliadin binds to enterocytes, creating a hybrid antigen to which immune system responds
8
Q
What is gliadin
A
Protein found in the gluten of wheat, rye and barely (oats are okay)
9
Q
Condns causing intestinal obstruction
A
Herniation
Adhesions
Volvulus
Intussusception
10
Q
Which autoantibodies are seen in coeliac disease
A
Reticulin
Endomysial transglutaminase
Most sensitive and spp - IgA endomysial ab
11
Q
Histology seen in coeliac disease
A
Viili disappear along the small bowel and the crypts deepen (hyperplasia)
Activated cytotoxic killer T-cell invade epithelium
12
Q
Endoscopy findings for coeliac disease
A
Abnormally smooth gut mucosa
13
Q
Px of coeliac - GI
A
Diarrhoea and steatorrhea
Abdo pain
Bloating
Wt loss
14
Q
Px of coeliac - extra intestinal
A
Anaemia (malabsorption of iron and folate)
Osteoporosis - Ca and vit D malabsorption
Mouth ulcers
Dermatitis herpetiformis
Infertility
15
Q
Px of coeliac in young children
A
Diarrhoea and/ or constipation
FTT
Vomiting
Abdo protrusion
16
Q
Epidemiology of coeliac
A
Prevalence is 1/100
Px at any age but small peak in 1-3yrs (when first exposed to gluten)
17
Q
Risk factors for coeliac
A
Fhx
AI disease - T1DM, thyroid disease
IgA deficiency
18
Q
Natural hx of coeliac
A
10% of pts eventually get 1’ lymphoma if not properly treated
Osteoporosis
19
Q
Dx of coeliac
A
Anti-tTG IgA (can also use IgG)
Endomysial ab is more spp but less sensitive
Bx via upper endoscopy to confirm dx
HLA-DQ2/8 typing if dx unclear
20
Q
What is is necessary for accurate coeliac ix
A
Pts should stay on gluten while under ix to ensure test accuracy
21
Q
Extra tests for coeliac
A
FBC - anaemia
LFT - may see raised transaminases
Ca and albumin (low)
DEXA
Skin bx for dermatitis herpetiformis
22
Q
Screening for coeliac
A
1st degree relatives w/ coeliac
23
Q
Causes of villous atrophy
A
Whipple’s
Lymphoma
Peptic duodenitis
Acid damage to duodenum
24
Mx of coeliac
Life-long gluten free diet
Replace micronutrients if deficient
25
Monitoring for coeliac disease
Annual review
DEXA 1-3yrs after dx, and at menopause (55 in men)
26
IBD
Infl bowel disease
Incl Crohn's disease and ulcerative colitis
27
What is Crohn's disease
Systemic disease non which ulcers and fibrosis, often w/ granulomas, affect portion of the alimentary canal
28
Crohn's disease morphology
Transmural involvement (all three layers)
Ulcers on mucosa - fissures and cobble stoning
Wall is oedematous w/ narrowed lumen
Fat tends to 'creep around' mesentery
Increased goblet cells
29
Crohn's disease lesions
Lesions are sharply demarcated from normal regions (skip lesions)
Most common site of involvement is terminal ileum
30
What are pt's w/ CD prone to, since any portion of the gut can be involved
Apthae in mouth
Scleorosing cholangitis
Perianal abscesses, fistulas and fissures
31
Systemic sx seen in CD
Same as infl enteropathy
Arthritis
Uveitis
Erythema nodosum, pyoderma gangrenosum
If HLA-B27, ankylosing spondylitis
32
Epidemiology of IBD
Prevalence is 1/600 in CD and 1/1000 in UC
Bimodal onset: 15-30yrs and 60-80
33
Sx of CD
Diarrhoea - bloody in 25%
RLQ pain
Wt loss
Fever
Fatigue
More likely to present acutely
34
Signs of CD
Perianal = abscesses, fistula, tags
RIF mass from infl of terminal ileum
35
Hepatobilary signs of CD
Gallstones
C/c hepatitis, NAFLD and cirrhosis
36
Risk factors for CD
Smoking
Fhx
NOD2 mutation
Caucasians
37
Ix for IBD - blood's
Increased CRP/ ESR, platelets (low albumin)
Anaemia
LFT for associated hepatobiliary disease
U&Es for nutritional deficiencies
38
Ix for IBD - stool
Culture to rule out infection
Faecal calprotectin - marker of infl
C. diff - poor prognostic marker
39
Endoscopy for CD
Skip lesions
Cobblestoning appearance
Apthous ulcers
Bx - transmural disease w/ granulomas
40
Small bowel enema - radiological findings for CD
Strictures - Kantor's string sign
Rose thorn ulcers
Proximal bowel dilation
41
Complications of IBD
Obstruction - CD
Fistula - CD
Colorectal cancer - higher in UC than CD
42
Inducing remission in CD attack
Methylpred IV 3/7 then pred PO 2/52
If refractory: add azathioprine or add/ switch biologic
May give enteral nutrition therapy
43
Indications for treatment for CD
Freq relapses
>2 steroid courses per yr
Relpase <6/52 after stopping steroids
44
Drugs for maintaining remission in CD
Azathioprine or mercaptopurine
May give MTX or biologics
45
Use of biologics in treating CD
Can be used for induction and maintenance for refractory severe disease
Examples incl infliximab or adalimumab
46
Drugs given for symptomatic relief of CD
Loperamide and an anti-spasmodic, but not during attacks
PPi for upper GI problems
47
Drugs given for perineal disease in CD
Oral metronidazole and/ or cipro
Topical mesalazine
Seton insertion for fistulae
48
Indications for surgical mx of CD
Needed in 70%
Medically refractory
Obstruction or perforation
Growth failure
49
What may extensive small bowel resection in CD cause
Short bowel syndrome
50
Features of short bowel syndrome
Diarrhoea
Steatorrhea
Electrolyte abnormalities
Malnutrition incl vit deficiency
Wt loss
Fatigue
51
Post-op recurrence of CD
30% in 1yr
Risk increased if smoker
52
Long-term surgical complications of CD procedures
Vit B12 deficiency, esp if >20cm removed
Bile salt malabsorption
53
Ulcerative colitis
IBD beginning in rectum and may extend to caeca,
Continuous pathology - NO skip lesions
54
Pathophys of UC
Continuous area of infl in rectum
Inflammable, friable mucosa w. crypt changes, reduced goblet cells and psuedopolyps
55
Intestinal sx of UC
Diarrhoea - bloody in 25%
Lower abdo cramps
Rectal sx - urgency, tenesmus
More likely to present gradually
56
Sx of UC attacks
Tender distended abdo
Fever
Anorexia and wt loss
May be triggered by infection
57
Non-intestinal sx of UC
Uveitis
Apthous ulcers (less than CD)
Clubbing
Erythema nodusum
Pyoderma gangrenous
Entero arthritis
58
Hepatobiliary sx of UC
PSC
C/c hepatitis, NAFLD and cirrhosis
59
Shared sx in IBD
Diarrhoea
Arthritis
Erythema nodosum
Pyoderma gangrenosum
Uveitis
60
Toxic megacolon
Complication of severe colon disease or infection - UC more likely
Bowel wall becomes paralysed due to lumen filled w/ toxins - increased release of NO, from inflamed bowel wall
Transverse colon dilation of >6cm
61
Risk factors for UC
Not smoking - less common in smokers
Fhx
HLA-B27
62
Endoscopy for UC
Sigmoidoscopy usually sufficient
Looking for mucosal granularity
Bx - crypt abscesses, loss of goblet cells
63
Mx of mild to moderate attack of UC
1st line - PR mesalzine if distal (descending colon, rectosigmoid) and PO if proximal
2nd line - Add pred
64
Criteria for severe attack of UC
>6 stools/ day, usually bloody
Plus one of: severe, tachycardia, anaemia, ESR > 30
65
Mx of severe attack of UC
Admit and give IV steroids
Then ciclosporin, biologic or subtotal colectomy if refractory
66
Drugs to maintain remission in UC - mild/moderate attacks
Mesalazine PO +/or PR if rectosigmoid
67
Most serious complication of UC
Adenocarcinoma of the colon - screen w/ colonoscopy every 3yrs, starting 10yrs after dx
Colectomy is probs advisable if mucosal cells begin to look dysplastic
Cancer risk continues even if disease is quiescent, approaches 100% in 30 yrs
68
Backwash ileitis
Involvement of the terminal ileum in UC
Small bowel is spared
69
Drugs to maintain remission in UC - severe attacks
Azathioprine or mercaptopurine PO
70
Drugs given for refractory moderate-severe disease
Anti-TNF alpha drugs
JAK inhibitors - tofacitinib
71
Indications for surgery for UC
Medically-refractory c/c or a/c UC
Toxic megacolon or perforation
Dysplasia or malignancy
72
Complications of a/c surgery for UC
Sepsis
Poor healing due to high dose steroids
73
Complications of UC
Perforation
Toxic megacolon
Colorectal cancer
VTE
74
Arterial supply of cervical oesophagus
Inferior thyroid artery
75
Venous drainage of cervical oesophagus
Inferior thyroid vein
76
Arterial supply of thoracic oesophagus
Oesophageal branches of the thoracic aorta
77
Venous drainage of thoracic oesophagus
Azygous system
78
Arterial oesophagus of abdominal oesophagus
L gastric artery
79
Venous drainage of abdominal oesophagus
Portal system via L gastric vein
80
What vertebral level os the gOJ found at
T11
81
Blood supply of fundus
Short and posterior gastric branches of splenic artery
82
Blood supply of pylorus
Gastroduodenal artery, branch of common hepatic artery
83
Venous drainage of stomach
Vein run parallel to the arteries
L & R gastric arteries drain into portal venous system
The short gastric vein and the L & R gastro-omental veins drain in the superior mesenteric veins
84
What key structure is housed in the duodenum
Ampulla of Vater
85
Is there a clear demarcation between the jejunum and ileum
No
Ileum is thicker and has more 'fatty mesentery'
Ileum contains more LNs and Peyer's patches
86
Arterial supply of duodenum
Proximal to major duodenal papilla - (branches of coeliac trunk) gastroduodenal artery and superior pancreaticoduodenal artery
Distal to the major duodenal papilla - (branches of SMA) inferior pancreaticoduodenal artery
87
Arterial supply of jejunum
Jejunal branches of SMA
88
Arterial supply of ileum
Ileal branches of the SMA
Ileocolic artery supplies the distal ileum
89
Venous drainage of duodenum
Superior pancreaticoduodenal vein --> portal vein
Inferior pancreaticoduodenal veins ---> SMV ---> portal vein
90
Venous drainage of jejunum and ileum
SMV ---> portal vein
91
Parts of the colon
Caecum
Ascending colon
Transverse colon
Descending
Sigmoid
Rectum
Anus
92
Arterial supply to the caecum and ascending colon
Midgut derived (SMA)
Ileocolic artery ---> colic, anterior caecal & posterior caecal
R colic artery
93
Arterial supply to transverse colon
Midgut & hindgut (SMA & IMA)
R colic artery (SMA)
Middle colic artery (SMA)
L colic artery (IMA)
94
Arterial supply to descending colon
IMA - L colic artery
95
Arterial supply to sigmoid artery
Hindgut (IMA)
Sigmoid arteries, branches of IMA
96
Venous drainage of the colon
Mesenteric veins parallel their corresponding arteries
SMV and IMV drain their respective structures
IMV fuses w/ splenic veins, which the fins SMV to form portal vein
97
Role of SMV in venous drainage of colon
Drains small intestine, caeca, and ascending and transverse colon
Via jejunal, ill, ileocolic, R colic and middle colic veins
98
Role of IMV in venous drainage of colon
Drains descending colon through the L
Drains sigmoid via sigmoid veins
Drains rectum via superior rectal vein
99
How can we differentiate between upper and lower GI bleeding
Ligament of Treitz
100
Causes of upper GI bleeding
Peptic ulcer
Oesophageal varices
Oesohagitis
Mallory Weiss tear
Upper GI cancer
AV malformation
101
Causes of lower GI bleeding
Diverticulosis
Haemorrhoids
Colorectal cancer
Mesenteric ischaemia
AV malformations
102
Haematemesis
Vomiting fresh or altered blood
103
Malaena
Passage of altered ("tarry") blood rectally
104
Haematochezia
Bright red rectal bleeding
105
Types of GI bleeding in relation to disease site
Haematemesis - proximal to ligament of Treitz
Melaena - usually upper gI
Haematochezia - usually oleo-colonic
106
Which layer do peptic ulcer usually penetrate
Muscularis mucosa
107
Where can HP survive
Gastric type mucosa in the stomach (metaplastic gastric mucosa in the duodenum, oesophagus (Barrett's))
Small bowel (Meckel's diverticulum)
108
How does HP survive in acid pH of stomach
Urease activity (converts urea to ammonia)
Motility
Proteases (digests protective mucus)
109
How does HP damage gastric type mucosa
Production of ammonia - increases pH
Enzymes - proteases, lipases, mucinases
110
How does NSAID use contribute to PUD
Causes damage to gastric epithelium topically
Causes systemic damage by inhibiting the production of prostaglandins by gasproduodenal epithelial cells
111
Ddx for PUD
Functional dyspepsia
GORD
Biliary pain
Gastric/ duodenal malignancy
Pancreatitis
Ischaemia
112
Initial assessment for peptic ulcer bleeding
Haemodynamic status
Risk stratification
Looking for possible causes
113
Stages in mx of upper GI bleeding
Initial assessment - A-E
IV fluid resus and transfusion (Hb < 7)
Pt should be NBM and supplemental oxygen given
Definitive treatment
Appropriate follow-up - endoscopy once stable
114
Physiological changes w/ hypovolaemia
Tachycardia
Peripheral shut down
Hypotension (BP may be well preserved in young and fit)
May see postural drop
Confusion
Oliguria
115
Grading haemorrhagic shock
(Hypovolaemic shock)
Looks at blood loss, pulse, BP, RR, urine output
116
Risk stratification for gI bleeidng
Rockall score - predicts mortality
Can be calculated pre endoscopy (max 7) or post-endoscopy (max 11)
117
Glasgow-Batchford score
Preferred by NICE pre-endoscopy for deciding upon timing of intervention
Cut-off for intervention is >1
Parametres incl urea, Hb, SBP, pulse, tachycardia
118
Timing of endoscopy following upper GI bleed
Dx requires endoscopy
Adequate resus required before endoscopy
Usually, 24hrs of admission
119
What to do when endoscopic therapy fails for upper GI bleeding
Embolisation (interventional radiology)
Surgery
120
When do you perform surgery for bleeding peptic ulcer
Minimal surgery necessary to control bleeding
Severe uncontrolled bleeding
121
What constitutes as severe uncontrolled bleeding in PUD
After failed endoscopic pretreatment
<60y, 2nd rebleed, 8 units transfused
>60y, 1st rebleed, 4 units transfused
122
Portal hypertensive bleeding
Spectrum of condns encompassing oesophageal, gastric and ectopic varices and portal hypertensive gastropathy
123
What gradient of pressure between portal vein and iVC is needed for the devlopment of oeopshagela varices
10mmHg
Normal gradient is 3-7
Pressure gradient and other factors within vary wall (Laplace's law) influence when varices bleed
124
Vasoactive therapy for variceal haemorrhage
Examples incl terlipressin (vasopressin analogue), octreotide
Reduces splanchnic blood flow and pressures in varices
125
Abx for variceal haemorrhage
Bacteraemia and subsequent sepsis v common
Prophylactic BSA reduce mortality - cipro, 3rd gen cephalosporin
126
Secondary prevention for varicella haemorrhagew
Treat liver disease
Variceal obliteration
Drugs - BB
Determine cause of PHTN
127
Complications of Sengstaken tube
Aspiration
Mucosal necrosis
128
What can be done if endoscopic therapy fails for bleeding varices
Confirm it is variceal in origin
Balloon tamponade - sengstake tube
Portosystemic shunting
129
TIPPS procedure
Transjugular intrahepatic portosystemic shunt
Shunts blood from portal veins to hepatic vein
'Rescue' therapy for refractory a/c bleeding
Definitive treatment for bleeding gastric varices
130
Complications of TIPSS
Procedural/ technical
Infection
Stent occlusion
Rebleeding
Encephalopathy
131
Structure of villi in small intestines
Epithelial cells in villi extend down into lamina proprietor to form crypts
Important cells reside in more protected crypts
Goblet cells produce mucous
Paneth cells produce lysosomes
132
Appearance of distal jejunum on AXR
'Stack of coins'
Because of valvular conniventes folds
133
Segmental contraction vs peristalsis
Segmental contraction - mixing bile and pancreatic enzymes w/ chyme, does NOT propel the chyme
Peristalsis - advances chyme
134
Different foods and peristalsis
Solid foods induce greater activity than liquid meals
Food high in glucose cause greater stimulation than ones high in FFA
135
What is digestion
The breakdown of large insoluble food molecules (proteins, lipids and carbs) to small water-soluble absorbable molecules
136
Production of gastric juice
Pepsinogen and HCl secreted into lumen
HCl converts pepsinogen to pepsin
Pepsin activates more pepsinogen, starting a chain reaction
137
Proteolytic enzymes from pancreas
Trypsin, chymotrypsin, carboxypeptidase
Break down to peptides to AAs
RNA/ DNA to nucleotides
138
Digestion of carbs
Salivary amylase
Pancreatic amylase
Glycoside hydrolyses e.g. maltose, sucrose
Fibre is resistant to hydrolyses and isn't digested
139
Digestion of lipids
Emulsifies in stomach and then in duodenum and upper small bowel with action of bile
Requires gastric lipase, pancreatic lipase, phospholipase and cholesterol esterase
140
Absorption of glucose
Requires transport proteins, GLUT in enterocytes
Transporter binds Na and caused conformational change, moving sodium and glucose intracellularly
Na dissociates into the cytoplasm so unloaded transporter reorients back into position
141
Inflow and outflow of GIT
IN - 2L food/fluid, 6.5-7L secretions
OUT (to recirculate) - 8.4L per day
Total loss - 100ml faeces
142
Vitamins and minerals absorbed in duodenum
Calcium
Iron
Fat soluble vitamins - ADEK, Mg
143
Vitamins and minerals absorbed in jejunum
Folate
Vitamin B6
Vit C
Thiamine
Niacin
144
Vitamins and minerals absorbed in ileum
Bile slats and acids
Vit C
Vit B12 and folate
Vit D
Vit K
145
Vitamins and minerals absorbed in large intetsine
Water
Sodium
Potassium
Chloride
Vit K
Biotin
146
Intestinal failure
Reduction of gut function to below minimum necessary for the absorption of macronutrients and/or water & electrolytes
TPN required to maintain health
147
Intestinal insufficiency
Reduction of gut absorptive function that does NOT require IV supplementation
148
Functional classification of intestinal failure
Type 1 - self-limiting
Type 2 - prolonged
Type 3 - long term
149
Type 1 intestinal failure
Post-op ileus
A/c infl
150
Type 2 intestinal failure
GI complictaion
EC fistula
Abdominal sepsis
151
Type 3 intestinal failure
Short bowel syndrome
C/c obstruction
Motility disorder
152
5 major condns causing intestinal failure
Short bowel syndrome
Intestinal fistula
Intestinal dysmotility
Mechanical obstruction
Extensive small bowel mucosal disease
153
Consequences of intestinal failure
Dehydration - treat w/ water & salt
Malnutrition - nutrition
154
Treating mild intestinal failure
Nutrition - oral supplements, oral glucose/ saline
Water & electrolytes - dietary adjustments, NaCl
155
Treating moderate intestinal failure
Enternal nutritiojn
Enteral electrolytes
156
Treating severe intestinal failure
Parenteral nutrition
157
Causes of short bowel syndrome
Massive intenstinal rescetion
Repeated intestinal resection
EC fistuale
Gastric bypass
Paediatric - intetsinal atresia, midgut volvulus
158
Complications of intestinal failure
Dehydration
Malnutrition
Complications of IV support
Psychological
Stoma care
159
Short bowel syndrome
Less than 2m of small bowel
160
Mx of short bowel syndrome
St Marks solution
Double strength dioralyte
Loperamide
Codeine
Lanreotide
S/c fluids and electrolytes
IV fluids
TPN
161
Intestinal failure operations
Reversal of stomas
Putting bowel back into continuity
Repair of fistulas
Stricturoplasty
Removal of obstruction
162
Intestinal failure operations
Reversal of stomas
Putting bowel back into continuity
Repair of fistulas
Stricturoplasty
Removal of obstruction
163
Pathophys of pancreatic cancer
Typically duct adenocarcinoma of the pancreatic head (80%)
164
Prognosis of pancreatic cancer
5-yr survival is 3.3%
15% are resectable at dx
Median survival is 28-54 months
165
Histology of pancreatic cancer
V poor vascularity
V fibrous - rich stroma in which cancer is embedded
166
Risk fcators for pancreatic cancer
Smoking, alcohol
C/c pancreatitis
Fhx
Diabetes
167
Sx of pancreatic cancer
B sx - wt loss, anorexia, fatigue
Worsening of DM/ new onset
Head tumours - PAINLESS obstructive jaundice (bile ducts blocked)
Body/ tail tumour - epigastric pain that radiates to back, relived leaning forward
168
Signs of pancreatic cancer
Palpable liver, GB and/or spleen - think Courvoisier's law
Jaundice
Ascites
Trousseau's sign
169
Courvoisier's law
Palpable GB w/ jaundice is rarely gallstones, consider malignancy (pancreatic or cholangiocarcinoma)
170
Trousseau's sign of malignancy
Migratory thrombophlebitis and hypercoagulability
May also be seen in gastric or lung cancer
171
Metastasis of pancreatic cancer
Presenting sx may be from mets
Commonly affects liver, lungs, peritoneum
172
Referral for pancreatic cancer
Over 40 w/ new onset jaundice - 2WW
Over 60 w/ wt loss and any of following - CT abdo:
Diarrhoea
Back pain
N & V
Constipation
New onset DM
173
Importance of cancer associated fibroblasts
Immunosuppressive
V dense fibrous tissue - hard for chemo to penetrate
V hypoxic enviuronment
174
Ix for pancreatic cancer
CT - CAP
CA19.9
Bx
Bloods - FBC, LFTs, bone profile, U&Es
Endoscopic ultrasound
175
General aspects of care for pancreatic cancer
Nutrition - PERT
Mental health
Psych support
Pain control - v important
Good palliative care
176
Chemo regimes for pancreatic cancer
Gemcitabine and Capecitabine
FOLFIRINOX
177
Surgical treatment for pancreatic cancer
Whipple's procedure (Pancreaticoduodenectomy) if resectable
Biliary stent insertion by ERCP
Total pancreatectomy
178
Epidemiology of a/c pancreatitis
Increased incidence w/ age
Common surgical emergency
179
Pathogenesis of a/c pancreatitis
Involves intra-pancreatic activation of pancreatic enzymes and auto-digestion
Infl ---> oedema, fluid shifts and hypovolaemia
180
Causes of a/c pancreatitis
Idiopathic
Gallstones (50%)
Ethanol
Trauma
Steroids
Malignnacy and mumps
AI
Scorpion bite
Hyperlipidaemia and hyperCa
ERCP
Drugs
181
Px of a/c pancreatitis
Sudden-onset epigastric or LUQ pain and tenderness - radiates to back, better leaning forward
N & V
SIRS
Pleural effusions and ascites if severe
182
What is required for a dx of a/c pancreatitis
2 out of 3 of:
Typical pancreatic type pain
Increased amylase or lipase (>3x ULN)
Compatible CT, MRI or US findings
183
Other causes of a raised amylase
Renal insufficiency
Salivary infl
Macroamylaseamia
Hereditary
Intestinal infarction/ peritonitis
Ectopic prehnancy an ovarian cyst
Appendicitis
184
Bloods for a/c pancreatitis
FBC - increased WBC, deranged RBC (low - haemorrhage, high - dehydration)
Increased CRP
Increased LFTs
Deceased Ca if severe
185
Imaging modalities for a/c pancreatitis
AXR
CXR
US
Abdo CT or MRCP - gold standard but only needed if dx unclear
186
XR for a/c pancreatitis
AXR - Dilated gut ('sentinel loop') next to pancreas
CXR - pleural effusion
187
US for a/c pancreatitis
May show pancreatic infl but mainly done to find gallstones
Repeat after a/c phase if gallstones found
188
Drugs that may cause a/c pancreatitis
Azathioprine
Valproate
Thiazides
Ceratin antimicrobials - metronidaxole, sulphonamides
189
Causes of pancreatic duct obstruction
Pnacreatic cancers
Ampullary/ periampullary cancers
Ascariasis
Duodenal cancers/ lymphomas/ mets
190
What should be done for pts w/ unexplained pancreatitis
ALL should have a CT scan within 6/52 of dx to check no malignant ductal obstruction
191
Addn sx of haemorrhagic pancreatitis
Bruising over both flanks (Grey-Turner's sign)
Bruising over peri-umbilicus (Cullen's sign)
192
Glasgow score to asses severity of pancreatitis
PaO2 < 8 kPa
Age > 55
Neutrophilia (WBC > 15)
Ca2+ < 2mmol/L
Renal impairment (urea < 16)
Enzymes (raised LDH, AST)
Albumin < 32
Sigar (glucose) > 10mmol
>3 is severe nd requires HDU admission
193
Initial mx of a/c pancreatitis
Supportive care - IV fluids (catheterisation and fluid balance chart), analgesia, antiemetics, nutritional support (NG or NJ tube)
Abx if signs of infection
Mx of aetiology
194
Complications of a/c pancreatitsi
Necrosis
Abscess formation
Peripancreatic fluid collections - seen by 2/52
Pseudocyts - 4/52
Pseudoaneurysm
VTE
195
Systemic complications of a/c pancreatitis
ARDS
Renal failure
Shock
196
Prognosis of a/c pancreatitis
20% mortality if severe
197
Interventional treatment for a/c pancreatitis
Necrosectomy
Drainage of pseudocyts
If due to gallstones, offer cholecystectomy or ERCP after recovery
198
What should be done for recurrent a/c pancreatitis
Mx of aetiology
Modify lifestyle
Consider rare causes e.g. genetic causes PSS-1, SPINK1 or AI pancreatitis (IgG4 level may be raised) - steroid responsive
199
What is c/c pancreatitis characterised by
C/c, progressive pancreatic infl and scarring
Resulting in the loss of exocrine and endocrine function
200
Most common causes of c/c pancreatitis
Alcohol
201
A/c vs c/c pancreatitis
C/c is less intense and longer lastlasting
Presence of exocrine or endocrine dysfunction in c/c
Lipase / amylase is typically NOT raised in c/c
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Clinical features of c/c pancreatitis
Recurrent or c/c epigastric pain radiating to back
Exocrine pancreatic insufficiency ---> steatorrhea and malnutrition
DM
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Ix for c/c pancreatitis
Blood glucose
CT (ideally) or US: pancreatic calcification
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Mx of c/c pancreatitis
Lifestyle - avoidance of triggers e.. smoking
Medical - pain relief, pERT
Endoscopic - relief of obstruction, stone removal, coeliac nerve block
Surgical - Whipple's, Frey
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Diagnostic test of pancreatic exocrine insufficiency
Faecal elastase - low levels
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Is 2' DM to pancreatitis common
No, relatively uncommon
Behaves like T1DM (destroyed islets)
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Pancreatic cancer risk and c/c pancreatitis
CP increases risk
Most significantly in those w/ genetic predispositions (SOPINK1) and cig smokers
No evidence for screening except in genetic group - done w/ CT abdo
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Key complications of c/c pancreatitis
C/c epigastric pain
Loss of exo/endocrine functions
Damage to duct system --> obstruction of excretion
Psudoecyts formation
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Risk stratification for GI bleeding
Rockall score - predicts mortality
Can be calculated pre endoscopy (max 7) or post-endoscopy (max 11)
Any pts w/ a score >0 erequire input
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Conservative mx of toxic megacolon
Bowel decompression - place pt NBM, insertion of NGT, IV fluids
Surgery indicated if pt isn't responding to mx or develops complications
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What features constitute 'problem drugs' for ADR
Benefit-harm ratio critically balanced e.g. digoxin, anti-coag
Poor kinetics (narrow range of safety) e.g. phenytoin
Enzyme inducers/ renal effects e.g. anticonvulsant
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What features constitute 'problem diseases/ susceptible pts' for ADR
Serious consequences of therapeutic failure e.g. anti-arrythmics
Disease required multiple drugs e.g. CHF
Pt is elderly or has multiple pathology
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Examples of how mechanism of drug action predicts interactions
Blocked AVN conduction - bradycardia
Arterial dilatation - hypotension
CNS drugs - sedation
Antiplatelets/ anti-coag - haemorrhage
HF drugs - electrolyte abnormalities
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What to do when anticipating drug interactions
Monitor drug levels or response e,g, iNR
Adjust dose if interactions e.g. reduce BB if on diltiazem
Correct metabolic disturbances
Monitor when using liver enzyme inducers or inhibitors
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What effect would an enzyme inducer cause if the enzyme breaks down drugs
Less drug in body, less drug action
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What effect would an enzyme inhibitor cause if the enzyme breaks down drug
More drug in body, more drug action
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What effects would an enzyme inducer cause if the enzyme activates drugs
More drug in body, more drug action
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What effect would an enzyme inhibitor cause if the enzyme activates drug
Less drug in body, less drug action
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Oral contraceptive interactions
Abx
Anticonvulsants
Encouraged to use barrier method
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Abx that potentiate the effects of warfarin
Metronidazole
Co-trimoxazole
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Which electrolyte does ACEi increase and what problems can this cause
K
Significant problem if given w/ K sparing diuretics, K supplements an drugs that worsen renal function
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Alcohol and CNS drugs
Potentates CNS depressants
Sedating antihistanes
Benzodiazepines
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Which drug class increases alcohol conc in body
H2RA e.g. ranitidine
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Alcohol as a vasodilator
GTN and alcohol
Increased risk of hypotension & fainting
Esp when GTN used within 1hr of alcohol
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What is an ADR
An unfavourable outcome that occurs during or after the use of a drug
Could be:
Abnormal sign, symptom or lab tests
Any untoward or unplanned occurrence (e.g. accidental/ unwanted pregnancy)
Unexpected worsening in a concurrent illness
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What is a side effect
Any unintended effects
May be harmful or beneficial e..g alpha-blocker for HTN - improvement in prostatic symptoms
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When to consider ADRs - narrow benefit: harm margin
Limited benefit but some risk of harm e.g. HRT
Some public health measures - flu vaccines
Major benefit but substantial harm e.g. cancer chemo
Older pts - multiple comorbidities and poly pharmacy
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Reporting ADRs
UK Yellow Card System
Particularly important for black triangle drugs - newly launches or suspected to have sig problems
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Classification of ADR
Type A - dose dependent, predictable
Type b - not dose dependent, cannot be predicted pharmacologically
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Limitation of classification of ADR
No account of duration e.g. steroid osteoporosis - dose and length of therapy are relevant
Susceptibility - poor mobile elderly women more likely
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Examples of Type A ADR
BB causes bradycardia, higher dose, greater degree of bradycardia
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Examples of Type B ADR
Anaphylaxis to penicillin
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Monitoring and predicting ARDS
DoTS scheme
Dose relatedness (at what dose does ADR happen)
Time relatedness (when does it happen, should I monitor for it)
Susceptibility factors (is pt at special risk)
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Digestion and GIT - mouth
Ground and mixed sallivary amylase
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Digestion and GIT - stomach
Mixing
Acid proteases
Reservoir w/ gradual release
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Digestion and GIT - small bowel
Bile
Pancreatic enzymes
Absorption
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Digestion and GIT - colon
Water absorption
Bacterial flors
[Short chain FA, vit K]
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Is the small intestine mobile or immobile
Mobile - attached by mesentery to posterior abdo wall
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Features of plicae semilunaris
Found in jejunum
Circular folds are large, tall and closely packed in upper jejunum
Gradually reduce until lower ileum where they are absent
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Where does the blood supply of the large intestine change
Proximal to splenic flexure - SMA
Distal to splenic flexure - IMA
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What vertebral level is the rectum at
S3
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How is CT colonoscopy done
Cleanse bowel using laxatives
Oral contrast agent
Put pts on low residue agency
CO2 via Foley catheter PR
Scan in two positions
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Indications for imaging small bowel
Previous admission for SBO
Unexplained IDA [OGD & colonoscopy normal]
Malabsorption
Unexplained pain/ diarrhoea/ wt loss esp w/ raised infl markers
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Crohn's disease radiological findings
Skip lesions
Ulcers
Fissures and oedema (cobble stoning)
Stenosis
Wall thickening and distortion
Fistulation
Infl mass and crypt abscesses
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Imaging suspected Crohn's
Barium studies - loss of haustrations, cobble-stoning, string sign
Ultrasound - blood flow using Dopple
CT enterography - infl fat wrapping
MR enter-graphs
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Indications for imaging large bowel
CIBH
PR bleeding
IDA
Palpable mas
Carcinomas and polyps
Dovertoculsar
Colitis
Volvulus
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What determines the premalignant potential of polyps (adenomas)
Size
1cm - 10% risk of being malignant
2cm polyps - 50% risk
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Types of colitis
IBD - UC, Crohn's
Ischaemia
Radiation
Infections (incl abx related)
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Imaging for suspected colon cancer
Colonoscopy - gold standard
Flexible sigmoidoscopy + CTC
CT CAP
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Imaging for suspected colitis
Rigid sigmoidoscopy
Colonoscopy
CT
251
Colonoscopy vs sigmoidoscopy
Coloscopy looks at entire colon but sigmooidoscopy is only lower 1/3rd
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Benefits of colonoscopy over CTC
Able to perform biopsies
253
Benefits of CTC over colonoscopy
Minimal prep required
Images can be reviewed after
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Anorexia
Reduced desire to eat
255
How can we classify causes of intestinal ischaemia
Occlusive - thrombosis, embolus
Non-occlusive - vasoconstriction, hypoperfusion
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Colonic ischaemia vs mesenteric ischaemia
Colin - large intestine
Mesenteric - small intestine
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Ix for intestinal ischaemia
CT pelvis and abdo
Erect CXR
Echo - if source of embolism suspected
Bloods - metabolic acidosis and raised lactate
Endoscopy
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Sx of intestinal ischaemia
Non-spp abdo pain
Diarrhoea
Haematochezia
N & V
259
Signs of intestinal ischaemia
Tenderness
Peritonism/ guarding
Tachycardia/ hypotension (haemodynamic instability)
260
Px of c/c mesenteric ischaemia
Triad of:
Post-prandial abdo pain
Wt loss - food avoidance
Abdo bruit
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Mx of intestinal ischaemia - thromboembolic cause
Anticoagulant
Broad spectrum abx due to bacterial translocation
May need resections
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Mx of c/c mesenteric ischaemia
Similar to CDV mx
Reduce modifiable risk factors
Implement 2' prevention
Revascularisation procedures may be performed
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Complications of intestinal ischaemia
Shock
Peritonitis
Sepsis
Necrosis
Perforation
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Barium enema findings for UC
Loss of haustrations
Superficial ulcerations
Psuedopolyps
In long-standing disease, colon in narrow and short - ‘drainpipe colon’
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Proctitis
Infl of rectum
266
Does UC affect the anus
No
