Upper GI and hepatobiliary Flashcards
What is gastric MALT lymphoma associated with?
H.pylori in 95% of cases
Features of carcinoma of the pancreas?
Development of jaundice in association with a smooth right upper quadrant mass is typical of distal biliary obstruction secondary to pancreatic malignancy.
Features of gallstones?
biliary colic or episodes of chlolecystitis
Prefered diagnositc test for chronic pancreatitis?
CT abdomen
Features of acute pancreatitis?
severe epigastric pain that may radiate through to the back
vomiting is common
examination may reveal epigastric tenderness, ileus and low-grade fever
periumbilical discolouration (Cullen’s sign) and flank discolouration (Grey-Turner’s sign) is described but rare
What is acute pancreatitis usually due to?
Alcohol or gallstones
What is the pathophysiology of acute pancreatitis?
autodigestion of pancreatic tissue by the pancreatic enzymes, leading to necrosis
Investigations for acute pancreatitis?
serum amylase
raised in 75% of patients - typically > 3 times the upper limit of normal
levels do not correlate with disease severity
specificity for pancreatitis is around 90%.
serum lipase
more sensitive and specific than serum amylase
it also has a longer half-life than amylase and may be useful for late presentations > 24 hours
imaging
a diagnosis of acute pancreatits can be made without imaging if characteristic pain + amylase/lipase > 3 times normal level
however, early ultrasound imaging is important to assess the aetiology as this may affect management - e.g. patients with gallstones/biliary obstruction
other options include contrast-enhanced CT
What is Boehaave’s syndrome?
spontaneous rupture of the oesophagus that occurs as a result of repeated episodes of vomiting. The rupture is usually distally sited and on the left side.
Diagnosis of Boehaave’s syndrome?
CT contrast swallow
Ascending cholagnitis features?
Charcot’s triad of right upper quadrant (RUQ) pain, fever and jaundice occurs in about 20-50% of patients
Systemic complication of acute pancreatitis
Acute respiratory distress syndrome
Aetiology of acute pancreatitis?
GET SMASHED
Gallstones
Ethanol
tRAUMA
Steroids
Mumps
Autoimmune
Scorpiton
Hypercalacemia and hyperlipidaemia
ERCP
Drugs
Drugs that induce acute pancreatitis?
azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate
WCC in ascending cholangitis?
Raised
Is primary biliary cholangitis painful or painless?
Painless
What is acute cholecystitis?
Inflammation of the gallbladder
Treatment of acute cholecytitis?
intravenous antibiotics
cholecystectomy- within 1 week of diagnosis
Risk factors for severe pancreatitis?
age > 55 years
hypocalcaemia
hyperglycaemia
hypoxia
neutrophilia
elevated LDH and AST
Investigations for chronic pancreatitis?
abdominal x-ray shows pancreatic calcification in 30% of cases
CT is more sensitive at detecting pancreatic calcification. Sensitivity is 80%, specificity is 85%
functional tests: faecal elastase may be used to assess exocrine function if imaging inconclusive
What is Reynold’s pentad?
Charcot’s triad (RUQ pain, fever and jaundice) plus hypotension and confusion
Acute pancreatitis management?
Fluid resuscitation
Analgesia
Nutrition
What is primary sclerosing cholangitis?
chronic liver disease in which the bile ducts inside and outside the liver become inflamed and scarred, and eventually narrowed or blocked.
Investigation used to screen for malignancy in patient’s with primary sclerosing cholangitis?
Raised CA 19-9 levels
Blood results in bilary colic?
Normal
What is bilary colic caused by?
gallstones passing through the biliary tree.
Pathogenesis of cholangitis?
Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile.
Pathophysiplpgy of cholangiocarcinoma?
Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis.
Management of ascending cholangitis?
intravenous antibiotics
endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction
Mnemonic for modified glasgow score to predict severity on pancreatitis?
PANCREAS
Most common complication of ERCP?
Pancreatitis
What is more useful for late acute pancreatitis presentations? Lipase or amylase?
Lipase
Best investigation for chronic pancreatitis?
CT pancreas
What is MALT lymhoma?
affects the mucosa-associated lymphoid tissue, usually around the stomach. It is associated with H. pylori infection.
What is acute cholecytitis?
Swelling of the gallbladder
What is Boerrhaves syndrome?
spontaneous rupture of the oesophagus that occurs as a result of repeated episodes of vomiting. The rupture is usually distally sited and on the left side.
Management of bilary colic?
elective laparoscopic cholecystectomy
Management of pseudocysts?
Observe for 12 weeks. May resolve. If not endoscopic or surgical cystagrsotomy or aspiration
best ways for differentiating between acute cholecystitis and biliary colic?
People with cholecystitis are systemically unwell
What is a hernia?
Protrusion of an organ into an abnormal space
What is affected In a hiatus hernia?
Most common hernia of the stomach herniating into the oesophageal
Why does hernia not often happen near diaphragm?
Liver blocks
Umbilical hernia vs paraumbilical hernia?
Umbilical is congenital
Why do hernias occur at Linea alba?
Thin area of abdomen
What is a spiegelian hernia?
Occurs where recutus abdomins stops (semilunar membrane)
Commonest incisions in surgery?
Putting lapdascopic ports in. Most common one is in umbilicus
Features you need to know about the hernia?
What is it
Is it fixable
Is it an emergency- obstructed or incaracerated
What is an obstructed hernia?
If the viscus In the hernia is obstructed
Why does an indirect inguinal hernia occur
Organ goes through deep and superficial inguinal
If can’t get above scrotal swelling what is that?
Hernia
Best way to check for reducibability?
Get patient to lie down and ask them if they can push the hernia back in
How to check if indirect hernia
Block deep ring. Get patient to cough. If hernia doesn’t come out it is an indirect hernia
How to complete a inguinal hernia exam?
Examine abdomen and scrotum
How to tell femoral hernia?
Lateral to inguinal ligament
Could also feel for femoral artery
Most common hernia in both genders?
Indirect inguinal hernia
Questions while examining hernia-
does it go in? Any other symptoms? How much trouble is it causing you?
Symptoms of oesophageal blockage
Dysphagia
Regurgitation
May still be having some bowel movements
Still produce wind
Symptoms of blockage at stomach?
Vomiting up more digested foods
Could be up to a day that the bowel blockage occurs
Acidic- Burn when coming up
Projectile vomiting
Symptoms of blockage at duodenum?
Bile
Vomiting up more digested foods
Could be up to a day that the bowel blockage occurs
Acidic- Burn when coming up
Projectile vomiting
Pancreatic juice- So more digested food
Symptoms of blockage at low part of small intestine?
Bile coloured vomit
Few days after meals so probably no particular relation you can spot
Wind and some stools possible
Distended abdomen
Symptoms of blockage at descending colon
Could present before even vomiting
Constipated
Possibly nothing or overflow diarrohea
Faecal vomit
Distended abdomen
Causes of oesophageal blockage
Tumour
Achlasia- Equal of solids and liquids and is much longer standing
Causes of stomach and duodenal blockage
Tumours- Stomach, duodenum, pancreas
In children pyloric stensois
Volvulus
Gallstone ileus
Causes of small bowel obstruction
Ileus
Tumours
Hernia
Volvulus
Gallstone ileus
Adhesions from previous surgeries
Causes of large bowel obstruction?
Tumour
Diverticulitis
Scarring
Signs in an obstruction of any part of GI system
Dehydrates
Low GCS
A- Worry of aspiration so put NG tube in. Could also give antiemetics. NBM
B
C- IV fluids
D- GCS- Vomiting metabolic alkalosis
E- Glucose. Low as vomiting and not eating
Investigations of obstruction of GI systems
AXR
CT would really pin point where and why
