W4: Upper GI Sx; Hepatobiliary Sx; Pancreatic Sx; CRC Sx; Pancreatic Disease; Liver Diseases; IBD; Flashcards
Management of upper GI disorders
OESOPH. CA.
endoscopy > biopsy > staging via CT
=> Ivor-Lewis Esophagectomy = gastro-oesoph anastamosis.
- ICU post-op, wound catheter
- Jejunostomy - tube to allow feeding during recovery
- oesophagectomy + ChemoT / RadioT (long recovery)
GASTRIC CA.: ALARMS; late dx
endoscopy; CT staging; Laparoscopy
=> CT shrink tumour then sx intervention
- endoscopic resection (early)
- partial/total gastrectomy (severity based)
GORD
endoscopy; pH studies and manometry
Laparoscopic hernia repair
SFX: dysphagia, difficult in belching + vomit
acute/chronic pancreatitis: principles and mgmt
- ACUTE PANCREATITIS: stone (↑intraductal pressure) alcohol (ox. dmg),
viral: CMV, Mumps
* CT: ?necrosis and complications. monitoring
* serum amylase
• abdo pain, collapse, nausea, pyrexic, dehydrated
=> ERCP + endoscopic sphincterotomy (w/ jaundice and cholangitis)
=> Tx of underlying acute cause
- CHRONIC PANCREATITIS: irreversible glandular destruction (OATIGER!)
* alcohol+smoking (dose-related)
* CF-CFTR mutation / SPINX1 mutation
* Coeliac disease higher risk to chronic pancr.
• abdo pain, exocrine insufficiency (BMI, Vit D., faecal/serum elastase), endocrine insuff. (DM)
MRI; CT, EUSS
=> ENDOSCOPIC THERAPY (ERCP): panc. duct dilatation (balloon)/stend/stone removal/papillary widening
=> lateral pancreaticojejunostomy (PUESTOW): ductal stone removal & anastamoses of pancr. + jejunum allowing direct flow of juice.
=> Sx drain: panc duct sphincteroplasty
=> Whipple’s
pancreatic cysts: principles and mgmt
- incidental CT MRI*
rf: jaundice, dilatedmain panc. duct
- EPITH. NEOPLASTIC - most common
* intraductal papillary mucinous neoplasm - main duct ca risk. 50yo+
- abdo pain, wt loss, N&V, jaundice
* mucinous cystic neoplasm: body & tail
-women
- pre-malign pot.
* serous cystic neoplasm: anywhere
- women
- non-cancerous - NON-EPITH. NEOPLASTIC
* pseudocyst
=> MDt referral
Pancreatic cancer: principles & mgmt
EUSS + biopsy. ↑Bilirubin,
=> EUS guided coeliac plexus block + NEUROLYSIS (supportive for unresectable)
=> ERCP + Metal stent
=> Radio Ablation: improves stent potency and increases survival
=> Palliative bypass / duodenal stent (duodenal obstruction)
*CA19-9 tum marker much better for tx response
Peritonitis: principles & mgmt
SYSTEMIC
FNA: culture and cell count etc.
=> Vancomycin (+ve)
=> Ciprofloxacin / Gentamicin (-ve)
Sx complications of chron. pancreatitis
p duct stenosis cyst bil. tract obstr. splenic vein thrombosis / gastric varices portal vein compression duodenal stenosis colonic stricture
Describe the common surgical management of Gall bladder disease gallstones
Non-Sx:
=> dissolution via oxycolic acid
=> Lithotripsy via high energy shock waves
Sx
=> Laparoscopic cholecystectomy
=> Open cholecystectomy | CI: infection risk
=> Mini cholecystectomy
=> single port
=> cholecystectomy: perforated (or risk) GB
Sx for common bile duct stone causing jaundice
=> * Lap. trans-cystic cbd exploration *
=> Lap. exploration of CBD (removal of stone + GB)
=> ERCP: retrieval
Describe the common surgical management of benign biliary tract disease
- 1º SCLEROSING CHOLANGITIS (inflamm of CBD + strictures. auIm)
=> Biothinning | Oxycolic Acid - Biliary Atresia
=> reconstruction + transplant - Choledochal Cysts
=> dilatation of bile duct - Biliary-Enteric Fistula (septic + biliary obstruction)
Gallstone ileus => Sx
Cholecystal duodenal fistula =>
Describe the common surgical management of jaundice due to malignant tumours
1. Cholangiocarcinoma => Mainly palliative d/t 10% being surgically resectable Sx bypass Stenting: ERCP or PTC RT ChemoT Photodynamic Tx Liver transplant
- GB Ca.
=> Radical Cholecystectomy - Ampullary Tumours
=> Pancreatico-duodenectomy
=> Endoscopic excision / Trans-duod. excision
Choledocholithiasis
Gallstones in common bile duct (vs cholelithiasis); incidental
1º - de novo; 2º jumped
- ascending cholangitis: jaundice, pyrexia pain++, rigors
- acute pancreatitis. obstructive jaundice
- post cholecystectomy
Gallstones: RF, presentation, dx
RF: F>M; cholesterol!; haemolytic anemias + bile infection
asymptomatic
vs
• dyspepsia (flatulence); colic
• acute cholecystisis (GB inflamm d/t cystic duct block)
- neutrophillia, temp, ↑CRP, LFT (ALT+AST)
• mirizzi syndrome
dx: LFT: ASP; ALT; ALP
Define the types of jaundice, differential diagnosis of intra and extra hepatic jaundice
- PREHEPATIC: unconjugated bil in urine
haemolytic nature | anemia; alcoholic jaundice - HEPATIC: conjugated, coloured urine
decompensation d/t cholestatic nature | spider naevi gynaecomastia ascites
IVDU, drugs
1º biliary cholangitis > cirrhosis: ↑ALP, AuIm: bile ducts aetiology
- POST-HEPATIC: conjugated. pale poo.
downstream blockage: cholelithiasis, CBD, extrahep bd obstruction: strictures, tumours
Interpret liver function tests
BILIRUBIN: bound to albumin and becomes soluble and conjugated.
AMINOTRANSFERASE: ALT:AST
=> ALD. Hepatocellular injury
GAMMA GT:
=>ALP + GGT = Liver source
=> Alcohol + NSAIDS
ALKALINE PHOSPHATASE (ALP): (bone; placenta; intestine) => bile duct obstructions
ALBUMIN: marker of synth. function
↓[ ] = chronic liver disease
PROTHOMRBIN TIME: scoring and transplant suitability
CREATININE: kidney funct. + transplant suitability
PLATELET: indirect marker of portal HT
thrombopoeitin
=> cirrhosis = splenomegaly
Chronic Liver Disease
↑lumen blood resistance w/ lymphocyte infiltration, ECM proteins, apoptotic hepatocyte.
activated kupffer cells + hepatic stellate
d/t: alcohol, AuImm., Haemochromatosis - Fe overload, Viral
Compensated CLD: routinely dilatated on screening + abn LFT
Decompensated CLD: Ascites; variceal bleeding; hepatic enceph (toxin/ammonia build-up
Hepatocellular Carcinoma: ↑risk w/ CLD
Ascites: complication of compensated.
Chronic Liver Disease Tx
=> Diuretics
=> Large volume paracentesis
=> TIPS: shunt ↓portal pressure
=> Aquaretics
=> Liver trnasplant
=> Laxatives, Neomycin (Hepatic Encephalopathy
Variceal Haemorrhage
Portal HT; blockages therefore porto-systemic anastamoses medical emergency
=> transfusion
=> endoscopic band ligation
+terapressin
+ TIPPS
Hepatocellular Carcinoma (Dx and Mgmt)
AFp tumour marker
USS, CT, MRI
=> resection
=> transplant lobule
=> ChemoT: Sorafenib TK inhibitor; Tamoxifen
=> Local. Ablative Tx: Alcohol injection / RadioT
Spontaneous Bacterial Peritonitis: What is it? And Mgmt
infection of ascitic fluid / endstage liver failure / sx cause
=> Ascitic Tap: [neutrophil] > [protein]
=> IV abx + IV albumin infusion
Alcoholic Hepatitis Mgmt
=> fluid resus, infection prophylaxis
=> BENZODIAZIPINE (alcohol withdrawal)
=> PPI (GI bleeds risk)
SEVERE (Glasgow Alcoholic Hep. Score >9) => PREDNISOLONE => Oral Steroids => Nutrition: *THIAMINE* B12 def. ?NG tube
Non-Alcohol Fatty Liver Disease
Steatosis => Steatohepatitis d/t obesity, DM, hypercholesterol., Alcohol
- FIB-4 score
- ↑↑AAT
=>Lifestyle mods
=> Metformin
=> Glucagon-like Peptide analogues
=> Vit E.
Viral Hepatitis
IgM: Active; IgG: Past; ALT
Hep A = Enteric; self-limiting acute
- Children
- ALT
- Faeco-oral, sexual, blood
Hep B = Parenteral. Acute self-resolve, Chronic complication
Hep C = Chronic complications only presentation
HIV + alcohol factors
=> PEGYLATED INTERFERON
=> ORAL ANTIVIRALS: TENOFIVIR
Hep D = resistant
Hep E = Fulimant Hep failure in pregnancy. Self-limiting.
Autoimmune Hepatitis
1) AuImm Hep: women. normal LFTs
Abn ANA; SMA | LIVER BIOPSY
=> steroids and long-term azathioprine
2) 1º biliary Cholangitis: female. ↑IgM and antimitochondria Ab
* pruritus + fatigue
=> UCDA
3) 1º Sclerosing Cholangitis: Male. pANCA Ab.
MRCP/MRI
=> Liver transplant + Biliary stents
Liver transplantation Scoring
Childs scoring
MELD
UKELD
Contraindications for liver transplantation
extrahepatic mets. vascular involvement substance/alcohol abuse psychological brain death active extra hepatic infection cardiopulm. comorbidities
State the common disorders affecting the small intestine with particular reference to malabsorption and the principles of their investigation and management
Nutritional DEFICIENCIES
INFECTION: Tropical sprue = folate def.; HIV Giardia parasite = villous atrophy
=> metronidazole
INFLAMM = MALABS.
* Coeliac: IgA, distal duodenal biopsy
inflamm d/t tissue transglutaminase, lymphocytic, ANTI-GLIADIN in children
+ Dermatitis herpenformis; AuImm Thyroid/Hepatitis/Gastritis, DM, PBC., Sjorgens, Downs
SIBO - Bacterial overgrowth: diagnosis + mgmt
Malabsorption = GI symptoms, osteomalacia
- H2 breath test, imaging of duodenal diverticulum
- *culture of s. bowel aspirate**
=> Abx rotation 2w each: - metronidazole - teracycline -amox. \+ vitamin and nutritional suppl.
Describe the signs of specific vitamin deficiencies
Vitamin C: scuvy
Ca2+, Mg2+, D: osteomalacia, tetany
B12: memory, dementia,
niacin: dermatitis
Vitamin K: increased PT
Vitamin A: night blindness
Define functional bowel disorders
nil detectable pathology; abdn gut function diagnosed via history+examination.
often good prognosis but significant effect on QoL: e.g. abdo pain, altered habit, abdo bloating, constipation (IBS)
- WHOLE TRACT
- PSYCHOOGICAL FACTORS
IBS (what?, investigations & mgmt options)
changes is normal function
- SIGMOIDOSCOPY*
- COLONOSCOPY*
- FIT testing: Hb in stool
- Stool culture
- Calprotectin: inflamm marker and IBD (raised)
=> education => dietetic review => FODMAP => anti-spasmodics (pain) => probiotics, linaeloride (bloating) => laxatives => antimotility (diarrhoea)
IBS critetia
ROME: abdo pain 3d+/3mos
=> improved w/ poop
NICE: “” +abdo bloat, exacerbate w/ eating
Non-ulcer Dyspepsia
multi-association, dyspeptic pain
H pylori Vs Uknown
=> eradication tx Vs Symptomatic treatment
IBD presentation and pathogen.
chronic relapsing/remitting inflamm
- dysbiosius
- genetic susceptibility (SNP=NOD2); environment; smoking
ULVERATIVE COLITIS
young,rectum to proximal colon
+extracolonic: erythema nodosum, uveitis, pyoderma gangrenosum
- ↓goblet
- crypt abscess + limited to mucosal inflamm
- faec.calp. significantly raised in UC
- ENDOSCOPY*; pseudopolyps
proctitis proctosigmoiditis l-sided colitis extensive colitis pancolitis
> bleeding, bowel perforation, toxic megacolon, malnutrition, DVT, CRC (∴ surveillance in LT UC)
ACUTE SEVERE COLITIS
4 stool cultures, cessation of NSAIDS, opiates, antidiarrhoeals, anticholinergics
=> IV glucocorticosteroids
=> IV hydration K/Mg
=> LMWH (thromboembolism risk in mucosal inflammatory diseases)
CROHN’S DISEASE
mouth ulcers, dysphagia, abdo pain, malaena
!smoking RF
- ENDOSCOPY* + CT/MRI complications
- GRANULOMA; transmural inflamm
- SKIP LESIONS
> LT: strictures, penetrating disease
colonic carcinoma risk
MICROSCOPIC COLITIS
-collagenous colitis
- lymphocytic colitis
=> AuIm: RA, CD, Thyroid
=> STEROIDS: budesonide
Truelove + Witts Criteria
GRADING OF UC
Mild:
Moderate: CRP+
Severe: ESR++ + CRP ++ +temp; tachyl anemia
Fulminant: cont. bleeding; abdo tend/distension; colonic dilatation
uc mgmt
(1) AMNOSALICYLCATES: induction and maintenance of remission
+CORTICOSTEROIDS: induction of remission in relapse (!sfx)
OR THIOPURINES: maintenance, but monitoring (lymphoma risk)
(2) BIOLOGICS - !demyelination;
(3) subtotal colectomy: rectal preservation; stoma (ileostomy)
cd mgmt
(1) STEROIDS induce remission
+ THIOPRINE maintenance (azathiprine or methotrexate)
(2) Sx for distal ileum scenario or for complications: strictures and fistulas
- drain and seton stitch - perianal CD + abx
Describe the Aetiology and presentation of colon cancer
RF: sporadic in male, low fibre, high meat, sedentary; underlying IBD, HNPCC FAP,POLYPS
- rectal bleed
- bowel habit
- anaemia
- mass
- chronic obstruction
- systemic symptoms
Describe the role of screening as applied to colon cancer
50-70y/o: FOBT every 2yr; +ve = colonoscopy
=>FIT test
- sigmoidoscopy
- detection pre-malignant adenomas
Describe the staging, treatment and prognosis of colorectal cancer
STAGING via CT, MRI, PET, rectal endo USS
DUKES STAGING: A - mucosa B - muscularis invasion C - muscularis + lymph node invasion D - distant mets
=> Sx resection => endoscopic resection => Adjuvant - Dukes C+B => RT and ChemoT => Laparoscopic
Describe the management of colorectal cancer
PRE-OPT: surgical excision + chemo to shrink; MRI vis.
*Faecal diversion = STOMA
ileostomy vs colostomy
* Faecal mesorectal excision; often IMA affected = C2,C3,C4 parasymp = CONTINENCE
POST-OP: vascular invasion, perineural invasion
Describe the presentation of colorectal cancer
rectal bleeding, !!6weeks symptomatic
= colonscopy + biopsy
Describe the aetiology, presentation and management of intestinal obstruction
Abdo pain +/-vomit, absolute constipation, abdo distension
> FLUID RESUS
otherwise conservative, based on aetiology
Sx for CLOSED LOOP OBSTRUCTION
Give an account of common anorectal conditions and their management.
chronic constipation
faecal incontinence
HAEMORRHOIDS: bleed on straining; tissue hyperplasia
=>rubber band ligation
=> HALO (ligation+USS)
=> Haemorroidectomy
FISSURES: pain++ d/t conspitation/hard faeces; !anal cancer
*flexible sigmoidoscopy
=> GTN ointment - diltiazem: HypoT headache
=> Botox; Spincterotomy
PERIANAL ABSCESS: RF-DM, BMI, imm suppr. trauma; pain+++ ?sepsis
=>abx
=>incision+drain
> ANOFISTULA ABSCESS: abn comm.; pus discharge
=>seton drain
=>sphincter preservation; incontinence risk
ANORECTAL CANCER
Fit +ve
Describe how colorectal imaging can be used in the diagnosis of common anorectal conditions
COLONIC TRANSIT STUDIES: constpiation
ANORECTAL MANOMETRY: sphincter function; pressure; length
recognise symptoms of a flare of IBD
bowel movements+++
presence of blood increasing
nil pyrexia until SEVERE + tachy + anemic + ESR 30+
IBD :complete appropriate assessment and investigations
=>steroids: induce remission
+Vit D/calcium
blood tests: CRP
+ stool cultures (infective risk – c difficile)
abdo xr
inflammatory markers sig. in IBD
Inflammatory markers in a flare of IBD often reveal a high CRP high platelets high WCC low albumin and anaemia
complete appropriate investigations and mgmt of IBD flareup
blood tests: CRP + stool cultures (infective risk – c difficile)
abdo xr
=>steroids: induce remission
+Vit D/calcium
consider appropriate therapy as per severity of clinical presentation for IBD exacerbation
+ assessment of severity of exacerbation
TRUELOVE-WITTS
SEVERE EXCABERATION: admit,
(1) => IV steroids + LWMH
(2) => Infliximab
+colectomy
TOXIC MEGACOLON: axr, descending if distended 5cm+, systemically unwell
=> colectomy + ileostomy formation
recognise complications of IBD flareup
toxic megacolon
perforation
abscess
infection
Traveller’s diarrhoea
Enterotoxigenic E.coli most commonly causes Traveller’s diarrhoea
Which antibiotics have a high risk for causing C. diff infection?
CCCC
ciprofloxacin
ceftriaxone
clarithromycin
co-amoxiclav
∴
=> oral metronidazole or vancomycin
the viruses that commonly cause diarrhoea and outline their epidemiology
ROTAVIRUS: children <5
*PCR
GIARDIA LAMBLIA: contamianted water supplies
*microscopy
NOROVIRUS: hospital and carehomes
*PCR
ENTAMOEBA HISTOLYTICA: foreign travel poor hygiene
- dysentry; amoebic liver cysts
- microscopy
Mgmt of diarrhoeal illness
=> rehydration
=> abx in dystentry, c diff., and imm suppr only
Pathogen most associated with chicken
Campylobacter spp. = diarrhoea with severe abdominal cramps.
*Stool cultures
=> rehydration
Diarrhoea associated with rural/agri exposure
E. coli O157
> haemolyric uraemic syndrome
=> abx+IV fluids
