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a2 me3031 alimentary > W4: Upper GI Sx; Hepatobiliary Sx; Pancreatic Sx; CRC Sx; Pancreatic Disease; Liver Diseases; IBD; > Flashcards

W4: Upper GI Sx; Hepatobiliary Sx; Pancreatic Sx; CRC Sx; Pancreatic Disease; Liver Diseases; IBD; Flashcards

1
Q

Management of upper GI disorders

A

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

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2
Q

acute/chronic pancreatitis: principles and mgmt

A
  1. 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

  1. 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

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3
Q

pancreatic cysts: principles and mgmt

A
  • incidental CT MRI*
    rf: jaundice, dilatedmain panc. duct
  1. 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
  2. NON-EPITH. NEOPLASTIC
    * pseudocyst

=> MDt referral

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4
Q

Pancreatic cancer: principles & mgmt

A

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

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5
Q

Peritonitis: principles & mgmt

A

SYSTEMIC

FNA: culture and cell count etc.

=> Vancomycin (+ve)
=> Ciprofloxacin / Gentamicin (-ve)

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6
Q

Sx complications of chron. pancreatitis

A 
p duct stenosis
cyst
bil. tract obstr.
splenic vein thrombosis / gastric varices
portal vein compression
duodenal stenosis
colonic stricture
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7
Q

Describe the common surgical management of Gall bladder disease gallstones

A

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

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8
Q

Describe the common surgical management of benign biliary tract disease

A
  1. 1º SCLEROSING CHOLANGITIS (inflamm of CBD + strictures. auIm)
    => Biothinning | Oxycolic Acid
  2. Biliary Atresia
    => reconstruction + transplant
  3. Choledochal Cysts
    => dilatation of bile duct
  4. Biliary-Enteric Fistula (septic + biliary obstruction)
    Gallstone ileus => Sx
    Cholecystal duodenal fistula =>
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9
Q

Describe the common surgical management of jaundice due to malignant tumours

A 
1. Cholangiocarcinoma
=> Mainly palliative d/t 10% being surgically resectable
Sx bypass
Stenting: ERCP or PTC
RT
ChemoT
Photodynamic Tx
Liver transplant
  1. GB Ca.
    => Radical Cholecystectomy
  2. Ampullary Tumours
    => Pancreatico-duodenectomy
    => Endoscopic excision / Trans-duod. excision
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10
Q

Choledocholithiasis

A

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
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11
Q

Gallstones: RF, presentation, dx

A

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

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12
Q

Define the types of jaundice, differential diagnosis of intra and extra hepatic jaundice

A
  1. PREHEPATIC: unconjugated bil in urine
    haemolytic nature | anemia; alcoholic jaundice
  2. HEPATIC: conjugated, coloured urine
    decompensation d/t cholestatic nature | spider naevi gynaecomastia ascites
    IVDU, drugs

1º biliary cholangitis > cirrhosis: ↑ALP, AuIm: bile ducts aetiology

  1. POST-HEPATIC: conjugated. pale poo.
    downstream blockage: cholelithiasis, CBD, extrahep bd obstruction: strictures, tumours
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13
Q

Interpret liver function tests

A

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

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14
Q

Chronic Liver Disease

A

↑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.

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15
Q

Chronic Liver Disease Tx

A

=> Diuretics

=> Large volume paracentesis

=> TIPS: shunt ↓portal pressure

=> Aquaretics

=> Liver trnasplant

=> Laxatives, Neomycin (Hepatic Encephalopathy

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16
Q

Variceal Haemorrhage

A

Portal HT; blockages therefore porto-systemic anastamoses medical emergency

=> transfusion
=> endoscopic band ligation
+terapressin
+ TIPPS

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17
Q

Hepatocellular Carcinoma (Dx and Mgmt)

A

AFp tumour marker
USS, CT, MRI

=> resection
=> transplant lobule
=> ChemoT: Sorafenib TK inhibitor; Tamoxifen
=> Local. Ablative Tx: Alcohol injection / RadioT

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18
Q

Spontaneous Bacterial Peritonitis: What is it? And Mgmt

A

infection of ascitic fluid / endstage liver failure / sx cause

=> Ascitic Tap: [neutrophil] > [protein]
=> IV abx + IV albumin infusion

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19
Q

Alcoholic Hepatitis Mgmt

A

=> 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
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20
Q

Non-Alcohol Fatty Liver Disease

A

Steatosis => Steatohepatitis d/t obesity, DM, hypercholesterol., Alcohol

  • FIB-4 score
  • ↑↑AAT

=>Lifestyle mods
=> Metformin
=> Glucagon-like Peptide analogues
=> Vit E.

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21
Q

Viral Hepatitis

A

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.

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22
Q

Autoimmune Hepatitis

A

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

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23
Q

Liver transplantation Scoring

A

Childs scoring
MELD
UKELD

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24
Q

Contraindications for liver transplantation

A 
extrahepatic mets.
vascular involvement
substance/alcohol abuse
psychological
brain death
active extra hepatic infection
cardiopulm. comorbidities
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25
Q

State the common disorders affecting the small intestine with particular reference to malabsorption and the principles of their investigation and management

A

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

26
Q

SIBO - Bacterial overgrowth: diagnosis + mgmt

A

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.
27
Q

Describe the signs of specific vitamin deficiencies

A

Vitamin C: scuvy

Ca2+, Mg2+, D: osteomalacia, tetany

B12: memory, dementia,
niacin: dermatitis

Vitamin K: increased PT

Vitamin A: night blindness

28
Q

Define functional bowel disorders

A

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
29
Q

IBS (what?, investigations & mgmt options)

A

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)
30
Q

IBS critetia

A

ROME: abdo pain 3d+/3mos
=> improved w/ poop

NICE: “” +abdo bloat, exacerbate w/ eating

31
Q

Non-ulcer Dyspepsia

A

multi-association, dyspeptic pain
H pylori Vs Uknown
=> eradication tx Vs Symptomatic treatment

32
Q

IBD presentation and pathogen.

A

chronic relapsing/remitting inflamm

  • dysbiosius
  • genetic susceptibility (SNP=NOD2); environment; smoking
33
Q

ULVERATIVE COLITIS

A

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)

34
Q

ACUTE SEVERE COLITIS

A

4 stool cultures, cessation of NSAIDS, opiates, antidiarrhoeals, anticholinergics

=> IV glucocorticosteroids
=> IV hydration K/Mg
=> LMWH (thromboembolism risk in mucosal inflammatory diseases)

35
Q

CROHN’S DISEASE

A

mouth ulcers, dysphagia, abdo pain, malaena
!smoking RF

  • ENDOSCOPY* + CT/MRI complications
  • GRANULOMA; transmural inflamm
  • SKIP LESIONS

> LT: strictures, penetrating disease
colonic carcinoma risk

36
Q

MICROSCOPIC COLITIS

A

-collagenous colitis
- lymphocytic colitis
=> AuIm: RA, CD, Thyroid

=> STEROIDS: budesonide

37
Q

Truelove + Witts Criteria

A

GRADING OF UC

Mild:
Moderate: CRP+
Severe: ESR++ + CRP ++ +temp; tachyl anemia
Fulminant: cont. bleeding; abdo tend/distension; colonic dilatation

38
Q

uc mgmt

A

(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)

39
Q

cd mgmt

A

(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

40
Q

Describe the Aetiology and presentation of colon cancer

A

RF: sporadic in male, low fibre, high meat, sedentary; underlying IBD, HNPCC FAP,POLYPS

  • rectal bleed
  • bowel habit
  • anaemia
  • mass
  • chronic obstruction
  • systemic symptoms
41
Q

Describe the role of screening as applied to colon cancer

A

50-70y/o: FOBT every 2yr; +ve = colonoscopy
=>FIT test

  • sigmoidoscopy
  • detection pre-malignant adenomas
42
Q

Describe the staging, treatment and prognosis of colorectal cancer

A

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
43
Q

Describe the management of colorectal cancer

A

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

44
Q

Describe the presentation of colorectal cancer

A

rectal bleeding, !!6weeks symptomatic

= colonscopy + biopsy

45
Q

Describe the aetiology, presentation and management of intestinal obstruction

A

Abdo pain +/-vomit, absolute constipation, abdo distension

> FLUID RESUS
otherwise conservative, based on aetiology
Sx for CLOSED LOOP OBSTRUCTION

46
Q

Give an account of common anorectal conditions and their management.

A

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

47
Q

ANORECTAL CANCER

A

Fit +ve

48
Q

Describe how colorectal imaging can be used in the diagnosis of common anorectal conditions

A

COLONIC TRANSIT STUDIES: constpiation

ANORECTAL MANOMETRY: sphincter function; pressure; length

49
Q

recognise symptoms of a flare of IBD

A

bowel movements+++
presence of blood increasing
nil pyrexia until SEVERE + tachy + anemic + ESR 30+

50
Q

IBD :complete appropriate assessment and investigations

A

=>steroids: induce remission
+Vit D/calcium

blood tests: CRP
+ stool cultures (infective risk – c difficile)

abdo xr

51
Q

inflammatory markers sig. in IBD

A 
Inflammatory markers in a flare of IBD often reveal a high CRP
high platelets
high WCC 
low albumin
and anaemia
52
Q

complete appropriate investigations and mgmt of IBD flareup

A

blood tests: CRP + stool cultures (infective risk – c difficile)

abdo xr

=>steroids: induce remission
+Vit D/calcium

53
Q

consider appropriate therapy as per severity of clinical presentation for IBD exacerbation

+ assessment of severity of exacerbation

A

TRUELOVE-WITTS

SEVERE EXCABERATION: admit,
(1) => IV steroids + LWMH

(2) => Infliximab
+colectomy

TOXIC MEGACOLON: axr, descending if distended 5cm+, systemically unwell
=> colectomy + ileostomy formation

54
Q

recognise complications of IBD flareup

A

toxic megacolon
perforation
abscess
infection

55
Q

Traveller’s diarrhoea

A

Enterotoxigenic E.coli most commonly causes Traveller’s diarrhoea

56
Q

Which antibiotics have a high risk for causing C. diff infection?

A

CCCC

ciprofloxacin
ceftriaxone
clarithromycin
co-amoxiclav

∴
=> oral metronidazole or vancomycin

57
Q

the viruses that commonly cause diarrhoea and outline their epidemiology

A

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
58
Q

Mgmt of diarrhoeal illness

A

=> rehydration

=> abx in dystentry, c diff., and imm suppr only

59
Q

Pathogen most associated with chicken

A

Campylobacter spp. = diarrhoea with severe abdominal cramps.

*Stool cultures

=> rehydration

60
Q

Diarrhoea associated with rural/agri exposure

A

E. coli O157

> haemolyric uraemic syndrome
=> abx+IV fluids

a2 me3031 alimentary (7 decks)

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