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YEAR 2 GI > Week 4 > Flashcards

Week 4 Flashcards

1
Q

How do the conditions for bacteria change from mouth to anus?

A

Becomes increasing anaerobic

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2
Q

Bacterial density changes along the GI tract how?

A

Becomes more so the further along the GI tract you go

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3
Q

How quickly food travels through GI tract means what about toxins?

A

Affects exposure to toxins consumed. I mean, food it literally in the colon for 10 hrs to several days, Vs 3-5 hrs on the small intestine

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4
Q

When is your personal microbiota fairly constant?

A

Well like from toddler, through to adult, through to maybe like 65 at elderly age where it may change a little

NB babies, at the moment, are considered sterile before birth. Then diet expansion means change microbiota

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5
Q

6 things the gut microbiota does

A

1) defence against pathogens
2) modification of host secretions (mucin, bile, gut receptors etc.)
3) metabolism of dietary components
4) production of essential metabolites to maintain health
5) development of the immune system- immune priming
6) gosh signalling with gut-brain axis

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6
Q

How does the gut microbiota helps with defence against pathogens?

A

Competition
Barrier function
pH inhibition

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7
Q

What type of food actually feeds the microbiota?

A

Fibrous food - though doesn’t actually give much energy aha

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8
Q

Benefits of dietary fibre?

A

Improves faecal bulking - shorter transit time so less toxin exposure
Metabolism of it = antioxidants, vitamins etc

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9
Q

Bacterial fermentation of the fibre leads to what

A

Maintains slightly acidic pH

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10
Q

Digesting fibre takes energy, meaning high epithelial cell turnover, = what

A

Less disease

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11
Q

Metabolism of the gut microbiota varies as you go along. Where is turnover rapid vs not?

A

Right/proximal cells has high turnover.
Vs turnover slow in the left side.

That is why colorectal cancer is more often on the left side, and more serious on the right hand side

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12
Q

Is the left or right side of the colon more carb rich?

A

Right/proximal side more carb rich

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13
Q

Most bacterial fermentation occurs on which side of the colon

A

Right

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14
Q

Short chain fatty acids mainly produced on which part of the colon

A

Transverse

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15
Q

Major product of carb metabolism?

A

Short chain fatty acids
Also gases! (CH4, H2, CO2)

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16
Q

pH acidic Vs neutral which side of colon?

A

Slightly acidic right, neutral on the left.

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17
Q

Three important short chain fatty acids produced by gut microbiota?

A

Butyrate
Propionate
Acetate

Right side of the colon

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18
Q

Why does the body accept the microbiota?

A

Because the immune system essentially ‘grew up’ with it

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19
Q

More protein fermentation occurs where in the colon?

A

Left side of the colon

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20
Q

Bacterial fermentation does what to the pH

A

Lowers, leading to pathogen inhibition

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21
Q

Link between IBD and microbiota?

A

Inflammation could be an immune response to microbiota. Anyways

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22
Q

What do antibiotics do to the microbiota?

A

Reduces diversity

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23
Q

Explain the barrier effect of the gut microbiota as defence against pathogens?

A

Commensal bacteria close to the epithelium block and prevent adhesion/colonisation by pathogens

These are present in the mucosal layer

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24
Q

How might diarrhoea alter microbial composition?

A

Decreased transit time

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25
Q

In IBD, the desire to eat less fibre may lead to what?

A

Changes in the microbiota

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26
Q

MS is linked to the dysbiosis of gut microbiota, true or false?

A

True

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27
Q

Dysbiosis if the gut microbiota is linked to autoimmune diseases such as

A

Rheumatoid arthritis

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28
Q

“Dysregulation of immune response leads to chronic gut inflammation” what is this describing?

A

IBD

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29
Q

Faecal microbial transplant may occur in a patient with recurring C. difficile . What is the efficacy of this treatment?

A

High

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30
Q

Prebiotics Vs probiotics

A

Pre = food for microbiota
Pro = actual bacteria

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31
Q

Effect of carbs in the numbers of butyrate producing bacteria?

A

Decreased carb intake

Significant decrease in numbers of butyrate producing bacteria

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32
Q

What does butyrate do about colon cancer?

A

Protects against development of colon cancer

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33
Q

Prebiotics do what to SCFA production by gut microbiota?

A

Stimulates it.

SCFAs are important for control of body weight, and insulin sensitivity

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34
Q

Increased consumption of dietary fibre increases risk of colon cancer

A

False

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35
Q

How common is acute GI bleeding?

A

Very

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36
Q

Before a case of acute GI bleeding, a few weeks history may look like?

A

Dyspepsia
Reflux
Epigastric pain

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37
Q

Heart burn Vs indigestion?

A

Heart burn = stomach acid into oesophagus

Heart burn is a type of indigestion.

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38
Q

Dyspepsia Vs heartburn location

A

Dyspepsia = pain/discomfort behind upper abdomen
Burning pain behind breastbone = heart burn

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39
Q

What feature “separates” (not literally) the upper and lower GI tract?

A

Ligament of treitz
So upper is proximal to the ligament, whilst lower is distal

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40
Q

Magenta stools usually in upper or lower GI bleeding?

A

Lower

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41
Q

Is upper or lower GI bleeding elevated urea?

A

Upper.
Normal urea in the lower GI tract

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42
Q

Is upper or lower GI tract associated with dyspepsia, reflux and epigastric pain, Vs typically painless

A

Upper = pain

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43
Q

Haematemesis is upper or lower GI tract bleeding?

A

Upper

Lower is more likely to be fresh blood, Vs upper = partially digested blood

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44
Q

Upper or lower GI tract bleeding is associated with Non steroidal anti-inflammatory use

A

Upper

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45
Q

Why elevated urea in upper gi bleeding

A

It’s partially digested blood, = haem, = urea

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46
Q

Two common, general causes for upper GI bleeding?

A

Ulcers (in all areas)
And
“Itis” = inflammation.

Eg
Oesophagitis
Gastritis
Duodenitis

(Tend to bleed in the context of abnormal clotting)

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47
Q

What’s a Mallory Weiss tear?

A

Test due to vomiting

Could be a cause of upper GI bleeding

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48
Q

Why might oesophageal varices occur???

A

Due to liver diseases. Eg cirrhosis = portal Hypertension, blood starts to go elsewhere, so you get oesophageal varices i.e. dilated submucosal eos veins connecting portal and systemic circulations

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49
Q

Why might you ask about peeing with GI bleeding?

A

No pee could indicate loss of circulating volume

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50
Q

What drug history do you ask about for peptic ulcers?

A

NSAIDs

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51
Q

Family history of peptic ulcers may raise suspicion of what possible infection

A

H pylori

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52
Q

How does a peptic ulcer happen

A

1) damaging force e.g. gastric acidity, peptic enzymes
against this is defensive forces of like, regeneration, bicarbonate, surface mucin

2) but increased injury - eg alcohol, NSAIDs, h pylori infection, ciggies, gastric hyper acidity, OR like ischaemia, shock etc

3) ulceration formation. With necrotic debris, inflammation, granulation tissue, little fibrosis etc.

Chronic amount of peptic ulceration = increases risk of carcinoma

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53
Q

Which type of upper GI ulcers are more common

A

Duodenal

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54
Q

Risk factors of peptic ulcers

A

H pylori
NSAIDs/ aspirin
Alcohol excess
Systemic illness- stress ulcers

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55
Q

How does h pylori help cause a peptic ulcer?

A

1) penetrate mucus layer, adheres to epithelial cells in gastric mucosa
2) bacteria releases urease to convert urea to ammonia as a higher pH buffer around it.
3) but then the body increases acid. This leads to loss of mucus, epithelial cell inflammation and damage etc

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56
Q

What’s diuelafoy?

A

Submucosal arteriolar vessel eroding through mucosa

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57
Q

Example causes of lower GI bleeding

A

Diverticular disease
Haemorrhoids
Vascular malformations
Neoplasia eg polyps
Ischaemia colitis
Radiation
IBD

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58
Q

What’s diverticula disease

A

Protrusion of the inner mucosal lining through the outer muscular layer, forming a pouch

Usually self limiting

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59
Q

What’s a haemorrhoid

A

Enlarged vascular cushion around anal canal
Painful if thromboses
Association with straining/constipation/low fibre diet
Common/ rarely serious bleeding

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60
Q

Treatment of haemorrhoid?

A

Treatment of elective surgical intervention

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61
Q

Ischaemic colitis is what

A

Disruption in blood supply to the colon

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62
Q

How does ischaemic colitis present?

A

Crampy abdominal pain
It’s often self limiting

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63
Q

Radiation procitis can lead to lower GI bleeding. Has history of radiation for what cancers? (Typically)

A

Cervical and prostate cancer

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64
Q

Chronic loss of blood through radiation proctitks could lead to what treatment?

A

Blood transfusion treatment

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65
Q

IBD often has acute lower GI bleeding, true or false

A

False
Usually slower onset, with diarrhoea symptoms

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66
Q

If no small bowel bleeding for GI bleeding cause is found, what could it be?

A

Meckels diverticulum
Or
Small bowel ulceration eg NSAID associated

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67
Q

What to do if someone presents to A&E with GI bleed?

A

Resus.
Diagnose and figure out treatment.
Then endoscopy once stable.
Consider meds e.g. PPI (espc. for peptic ulcer)

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68
Q

Possible management for varices?

A

Band ligation
(Leads to damage to blood vessels, and therefore necrosis, goodbye varices)

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69
Q

Is the duodenum retroperitoneal or not?

A

Yes it is

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70
Q

Is the jejunum retroperitoneal or not?

A

No. Jejunum is actually IN the peritoneal cavity

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71
Q

Ascending and descending Vs transverse, which is retro

A

Ascending and descending is retro

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72
Q

There villi in the large bowel?

A

No

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73
Q

So we’ve got the meisseners plexus and the auerbachs plexus. Which, as the myenteric plexus, mediates peristalsis?

A

Trick question
Obvs both is the myenteric plexus
So both control peristalsis

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74
Q

Name the 5 types of inflammatory bowel disease

A

UC
Crohns
Ischaemic colitis
Radiation colitis
Appendicitis

NB you also get idiopathic inflammatory bowel disease-

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75
Q

Idiopathic bowel disease definition (crohns and UC- they are idiopathic)

A

Chronic inflammatory conditions resulting from inappropriate and persistent activation of the mucosal immune system, driven by normal presence of microbiota

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76
Q

In IBD, defects in the normal surface barrier function of epithelium leads to what?

A

Exposure to the underlying lamina propria, and the immune cells, to normal flora- that doesn’t normally happen

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77
Q

Diagnosis of IBD requires clinical history, radio graphic examination, and pathological correlation. What presence of antibody is associated, as well?

A

Perinuclear antineutrophilic cytoplasmic antibody

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78
Q

If UC is limited to the rectum, what is it called?

A

Proctitis

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79
Q

UC is limited to the colon. So what’s backwash ileitis?

A

It spreads slightly through the ileocecal valve, into the terminal ileum.

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80
Q

Are there Granulomas for ulcerative colitis?

A

No

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81
Q

How does neoplasia secondary to colitis?

A

Keep repairing epithelia cells, then green tic defects and dysplasia

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82
Q

Is IBS a structural or functional disorder?

A

Functional

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83
Q

Functional GI disorders have a large impact on quality of life, and a large cause of work absences. Most functional GI disorders can be diagnosed with history examination, true or false.

A

True
Usually don’t need expensive or invasive investigatiosn

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84
Q

Retching Vs vomiting?

A

Retching is dry heaves, antrum contracts, glottis closed

Vomiting is where the contents are actually expelled

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85
Q

If you vomit immediately after food, then it’s often:

A

Psychogenic

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86
Q

If we vomit like an hour or more after food, issue is further down the GI tract. If it’s an hour or more, think of an example of why we’re bringing up?

A

Pyloric obstruction

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87
Q

If vomiting more than 12 hours later, obstruction where?

A

Maybe small bowel obstruction

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88
Q

With functional disorders, why is a short symptom history suggestive of more serious pathology?

A

Functional symptoms are usually present for longer period

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89
Q

Why do we ask about nocturnal symptoms with functional bowel disorders?

A

They wouldn’t usually bother patients at night

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90
Q

For bowel issues, why do we take a detailed drug history e.g. ask about recent antibiotic use?

A

This can cause opportunistic infections like clostridium difficile

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91
Q

Thyroid disorders can present with changes in gut function. For example an overactive vs under active thyroid can present with what stool

A

Over- active = diarrhoea
Under- active = constipation

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92
Q

Constipation doesn’t mean hard poo. What does it mean?

A

Bowel doesn’t get properly emptied/ emptying too infrequently

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93
Q

Psychiatric disorders such as depression or psychosis are often associated with what bowel issues?

A

Development of constipation

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94
Q

Hypercalcaemia can cause what bowel issue?

A

Constipation

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95
Q

What’s ‘colicky’ pain?

A

A pain that starts and stops abruptly.
It occurs due to muscular contractions in an attempt to relive an obstruction by forcing contents out. It may be accompanied by sweating and vomiting.

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96
Q

Could ‘colicky pain’, with altered bowel habit and abdominal bloating, without weight loss of blood, normal exam and bloods, be what?

A

IBS

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97
Q

For IBS, often we need to see that symptoms do what with eating and defecating?

A

Worse with eating
Better with defecating

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98
Q

How might a patient describe IBS pain?

A

Spasm
Burning
Sharp
Similar to period pain
Often radiating to lower back

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99
Q

IBS patients have an increase or decrease in gut feedback?

A

Increase

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100
Q

Altered bowel habits for IBS- is this more co stop action or diarrhoea?

A

Can be either or both. Often with a sense of urgency.

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101
Q

Why bloating in IBS?

A

Relaxation in abdominal wall muscles

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102
Q

Mucus in stool present in what disease?

A

IBS

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103
Q

When thinking about IBS, why do we check coeliac serology?

A

Because IBS has very similar symptoms to coeliac disease

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104
Q

Calprotectin is an inflammatory protein that helps us to distinguish between IBD and IBS how?

A

It’s in uc and crohns. Can monitor IBD with it.

Nb IBD is crohns and uc
Nb calprotectin is higher in older patients anyway so not useful over 50 (plz fact-check this)

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105
Q

What food might you exclude for IBS?

A

Tea, coffee, alcohol, sweetener, lactose, gluten

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106
Q

Which finds abnormal findings on colonoscopy, IBS or IBD?

A

IBD

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107
Q

Which has elevated CRP, IBD or IBS?

A

IBD

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108
Q

What is IBS caused by?

A

Disturbance in gut-brain interaction. Leading to troublesome symptoms. It’s a functional disorder- no identifiable disease

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109
Q

Are all the meds available for IBS, always effective?

A

No

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110
Q

Why CBT in IBS?

A

To cope with symptoms like abdominal pain

Psychology has shown to be very effective in functional disorders.

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111
Q

In IBS, what may happen to peristaltic contractions after someone starts eating?

A

May be stronger

(Slightly unrelated but…There is a theory that the gut provides more signals in patients with functional bowel disorders to the brain, so we’re more aware of what’s going on in the gut. Eg slight need of hunger, or urge to defecate).

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112
Q

Guts response to stress in IBS?

A

Increased/ more sensitive.
Like it’s normal to get butterflies and diarrhoea in response to stress, but this response can actually become chronic in IBS

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113
Q

Bloody diarrhoea typical of IBS or Uc?

A

Ulcerative colitis

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114
Q

If the whole colon is affected, i.e. ‘pancolitis’, in UC, what will the patient need?

A

A colectomy

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115
Q

Does UC progress?

A

Obvs. It wasn’t always there.
1/3 of patients with ulcerative colitis will require a colectomy within 10 years of a diagnosis.

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116
Q

In procitis, inflammation is confined to what part of the bowel only?

A

Rectum only

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117
Q

Is there a sense of urgency with IBD?

A

Yes like 50% of patients

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118
Q

What sub type of UC requires you to ask if there is any history of receptive anal intercourse?

A

Procitis
Where inflammation only of the rectum

To see if positive for chlamydia or gonorrhoea

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119
Q

Albumin level in IBD?

A

Decrease

This is Vs CRP, and platelets which are higher

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120
Q

Elevated faecal calprotectin is 200ug/g. What would be a normal level?

A

0-50

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121
Q

Gold standard investigation for UC patients?

A

Colonoscopy and biopsies of mucus a

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122
Q

How is calprotectin produced?

A

Trigger
Activation of gut immune system, and generation of calprotectin from a number of cells eg epithelial, monocytes, neutrophils, etc.

Released into gut lumen, then into faecal stream.

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123
Q

What other diseases, apart from IBD, causes high calprotectin?

A

Gastroenteritis
Diverticulitis
Ischemic colitis

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124
Q

If acute severe colitis (colitis meaning Colin and rectum inflamed), we check stool cultures for which bacteria?

A

C. Diff

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125
Q

If acute colitis, we give IV what?

A

Steroids

Also make sure they are adequately hydrated
Also a lot of patients may have low potassium due to diarrhoea, so let’s correct that please

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126
Q

Crohn’s disease can start as simply inflammatory, but then it progresses to what?

A

Stricturing, and then the disease can become penetrating and cause a fistula.

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127
Q

How often are crohns anorexic?

A

Often

By that I mean, just poor appetite. They can also present with nausea and vomiting.

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128
Q

How often are crohns patients malabsorbed/ anaemic and vitamin deficiency?

A

If it’s significant disease in their small bowel.

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129
Q

Blood markers for crohns?

A

For markers of inflammation

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130
Q

Why look at stool cultures for crohns?

A

To rule out infection, if complaining of diarrhoea

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131
Q

There is a depleted number of what type of cell in ulcerative colitis?

A

Goblet cells

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132
Q

UC Vs crohns for crypt abscesses?

A

Both

(Though more in UC)

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133
Q

Why will most Crohn’s disease patients require surgery over their lifetime?

A

What starts as an inflammatory disease, soon progresses into a penetrating disease (transmural) that causes Stricturing, abscesses, and possibly at the end: fistulas

So need surgery to treat abscesses or fistulas

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134
Q

Smoking and IBD?

A

No smoking = higher risk for UC lol
Smoking = higher risk for crohns, increased risk of requiring surgery and increased risk of developing disease again after anastomosis or joins after surgery

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135
Q

Symptoms of peri anal crohns diseases?

A

Perianal pain
Pus secretion
Unable to sit down

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136
Q

What investigations for perianal Crohn’s disease?

A

MRI pelvis and examination under anaesthetic

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137
Q

What treatment for peri anal Crohn’s disease?

A

Surgery to drain abscess from fistula
Then also antibiotics

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138
Q

Extra-intestinal manifestations of IBD?

A

Eye problems
Liver problems like ‘primary biliary cholangitis’
Rashes
Mouth ulcers
Musculoskeletal problems

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139
Q

Do the extra-intestinal manifestations of IBD, run the same, or an independent course to the colitis?

A

Could be independent. Colitis May be in remission, and/or there could be no bowel symptoms, but there could be extra-intestinal manifestations

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140
Q

Give an example of skin rash/lesion seen in IBD?

A

Erythema nodosum

Raised tender nodules typically on the front of the shins

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141
Q

Patients with both ulcerative colitis, and primary sclerosing cholangitis, have an increased risk of what?

A

colorectal cancer

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142
Q

How could pancreatitis cause chronic diarrhoea?

A

Because of malabsorption

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143
Q

‘Colitis’, meaning inflammation of the colon, can be due to crohns and uc, but what else?

A

Infective or ischaemic colitis as well

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144
Q

Why do we screen patients with IBD for bowel cancer?

A

Cuz they’re at a high risk for it, as a long term consequence

145
Q

What might a patient with a poorer prognosis, with more frequent flares, of IBD actually look like?

A

Someone diagnosed at a younger age
Those with perianal disease
Those who required steroids straight away

146
Q

Aminosalicylates are drugs used fin treatment for which branch of IBD?

A

UC but not crohns.

147
Q

Aminosalicylates for UC do what? (Aka 5ASAs)

A

Block prostaglandins and leukotrienes. They are topical to colonic mucosa.

Used in induction of remission, and maintenance or remission

148
Q

Are 5ASAs effective in Crohn’s disease?

A

No

149
Q

Can steroids be used in treatment for what IBD?

A

Both eg prednisolone

150
Q

Why not use steroids long term for IBD?

A

Because significant adverse side effects eg increased risk of diabetes, osteoporosis, cataracts, changes on mood, obesity

151
Q

Immunomodulation, which is used in maintenance of remission, is for which IBD?

A

Borh

152
Q

Methotrexate is an immunomodulator. Can it be used for both IBD?

A

No
Exception to rule
Just Crohns, not UC

153
Q

Biologics can be used for IBD, yea or no?

A

Ye

154
Q

How effective is elemental feeding in IBD? (Liquid food only).

A

Shown in cases to be as effective as steroids

Often gastric tube
But compliance low

155
Q

When do we operate in an emergency with IBD?

A

Acute severe colitis that’s not responding to high dose IV steroids. Perhaps with complications such as perforation, obstruction, and/or abscess

156
Q

When do we do elective surgery for IBD?

A

Patients with frequent relapses, despite medical therapy.
Patients who have become steroid dependent

157
Q

What exactly is the surgery done for acute severe colitis?

A

Subtotal colectomy.
So remove all of the large bowel, apart from the rectal stump.

So we keep rectum and small bowel. And ileum is brought out of the anterior abdominal wall as a stoma.

Patients can either have pouch procedure or total removal or rectum

158
Q

Why might a post surgery pouch not be great for those with Crohn’s ?

A

Crohns can actually recur, but IN the pouch. This can cause problems such as bleeding fistulas abscesses etc etc etc
Pouch can ultimately break down

Pouch is so you can reverse the stoma I think?

159
Q

Is ‘failure to thrive’ a surgical indication for Crohn’s disease?

A

Yes

160
Q

“Acute abdomen” definition

A

A combination of symptoms and signs, including abdominal pain, which results in a patient being referred for an urgent general surgical opinion

161
Q

Top three acute abdomen aetiology?

A

1) non specific pain
2) acute appendicitis
3) acute cholecystitis/colic

Then after that, peptic ulcer perforation, urinary retention

162
Q

Acute pancreatitis is most commonly related to what

A

Alcohol

163
Q

Passing urine with blood could be colic?

A

Yeah because tryna get rid of gall stones

164
Q

Abdominal aortic aneurysm can present as what

A

Pain left side, lower

We consider in this because we only have minutes to save their life

165
Q

Ectopic pregnancy could present as what

A

Acute abdominal lain

166
Q

Routes of infection for peritonitis, considering it’s closed off?

A

If perforation of peritoneal, can perforate GI/biliary tract, leading to sepsis

Female genital tract- only part of abdomen communicating with the outer world

Penetration of abdominal wall

Haematogenous spread (infection was IN bloodstream already)

167
Q

There are different types of bacteria in different places of the GI tract. Why is this fact clinically significant?

A

Cuz if eg peritonitis, where is route of infection therefore what bug to treat

168
Q

How is the omentum the ‘abdominal policeman?

A

Because if inflammation or local infection, then policeman will try and seal off, to localise infection in order to deal with it that way

So formation of abscesses
Eg appendicitis when omentum seals of the appendix

169
Q

What do I mean by ‘diffuse’ peritonitis?

A

Bugs all over the peritoneal cavity
Patient is having tenderness all over the abdomen

(Draining infection, not sealed off, made it diffuse as opposed to an abscess. Can open up abdominal cavity and wash it with saline. Solution of pollution is always dilution)

170
Q

Why is is anaerobic bacteria in an abscess, Vs aerobic bacteria in diffuse peritonitis?

A

Abscess is anaerobic because sealed off, not that much oxygen

171
Q

Generalised peritonitis represents failure of localisation and occurs when: (3)

A

1) contamination too rapid
2) contamination persists
3) abscess ruptures (eg fistulation)

172
Q

Why are abscess formations in the abdomen, related to vessels?

A

E.g. if an abscess erodes into e.g. common iliac vessel, will lead to a durational bleed. Patient can lose their life!!

173
Q

How are things obstructed eg ureter, bile duct etc? (Literally)

A

1) something actually in the hole
2) something presenting from outside
3) something in the wall

174
Q

Enlarged lymph nodes could cause obstruction in the bowel. Is this more common in paeds or adult practice?

A

Paeds as they have a larger lymphatic network within the bowel.

175
Q

Symptoms of intestinal obstruction

A

Pain
Vomiting
Distension
Constipation
Borborygmi

176
Q

How can you tell where the bowel obstruction is based on smell of vomit?

A

Smells like poo, = obstruction is further down

177
Q

What happens when there is an obstruction in the large bowel?

A

Can’t get back up into the small bowel. So bowel perforates. That’s a surgical disaster because of faecal contamination. And there is LOADS of bacteria in the colon!

178
Q

Abdominal pain can be one of three categories?

A

Visceral
Somatic
Referred

179
Q

What’s ‘visceral’ pain like and where does it come from?

A

From visceral peritoneum
It’s quite dull

180
Q

Will pain from parietal or visceral peritoneum tell us where the pain is from?

A

Parietal = pin point exact location

181
Q

In visceral pain , the body only recognises which three areas?

A

Foregut
Midgut
Hindgut

182
Q

Visceral pain is felt from receptors where?

A

Located in smooth muscle

183
Q

The appendix and Cecum is in foregut mid gut or hind gut? And therefore where is pain for appendicitis in the beginning?

A

Mid gut
So pain in the beginning is periumbilical pain.

184
Q

Why does the pain move over time in appendicitis?

A

Midgut i.e periumbilical.
Moved to right iliac fossa.

Because inflammation only affected visceral peritoneum at first, and now inflammation touches and affects the parietal peritoneum against the abdominal wall.

185
Q

Why will cholecystitis pain present as gastric pain?

A

The inflamed organ is within the foregut territory, because it’s visceral irritation

186
Q

How to cause parietal pain with inflamed gall bladder (cholecystitis)? (Murphy’s sign)

A

Put hand on diaphragm and under the liver…
Get patient to breathe, liver and inflamed gall bladder are pushed down and then touched parietal.
So sore the patient stops breathing.

187
Q

Somatic pain, receptors located where?

A

In parietal peritoneum or abdominal wall

Afferent signals pass with segmental nerves

188
Q

How could obstruction or peritonitis somewhere in the abdomen cause death?

A

Leads to fluid loss
And sepsis

Leads to circulatory collapse
Therefore death

189
Q

What to do to prevent circulatory collapse when there is fluid loss and sepsis?

A

Appropriate fluid
Appropriate antibiotic resuscitation
Oxygenation

190
Q

What’s the Sepsis 6 Campaign? (Mnemonic = BUFALO)

A

3 things to give: fluid, oxygen, antibiotics
3 things to give: lactate, blood culture and urine output

BUFALO=
Blood cultures
Urine output
Fluids
Antibiotics
Lactate
Oxygen

Find out why later

191
Q

What’s the management of acute abdomen?

A

Assess (+ resuscitate)
Investigate
Observe
Treat

192
Q

If the guy is full with fluid because it’s obstructed, how would you decompress the gut?

A

Catheter tube

193
Q

What is the definition of sepsis?

A

Life-threatening organ dysfunction due to a dysregulated host response to infection

194
Q

Why are the clinical features of sepsis variable?

A

It’s based on the underlying source of infection e.g. pneumonia, UTI etc

195
Q

There are localising symptoms, and there are systemic symptoms of sepsis. Give an example for either?

A

Localising: productive cough, dysuria
Systemic: drowsiness/ confusion due to profound hypotension causing cerebral hypoperfusion

196
Q

Sepsis can cause fluid retention, why?

A

Various reasons eg
Capillary leak syndrome
Increased vascular permeability as part of response to infection.
Decreased kidney function

197
Q

Why fluid resuscitation in sepsis?

A

IV fluids to maintain blood pressure and perfusion to vital organs

198
Q

In underlying liver disease, what do we do to dosage of paracetamol?

A

Reduce

Especially when they drink…

199
Q

Pancreatic cancer is commonest at what age?

A

Between 60 and 80 years of age

200
Q

5 year rate of survival for pancreatic cancer?

A

Like 7%

201
Q

Typical presentation of pancreatic cancer?

A

Obstructive jaundice&raquo_space;»

Also diabetes, abdominal pain, anorexia, vomiting, weight loss, recurrent bouts pancreatitis

202
Q

Golden, diagnostic imaging for pancreatic cancer?

A

CT

203
Q

Some cancers are detected by means of an ERCP during investigation and management of possible gallstone disease. What is an ERCP again?

A

Endoscopic retrograde cholangiopancreatography

Used to diagnose and treat problems in the bile ducts and pancreas.

Duodenoscope inserted through the mouth, down the oesophagus, and into duodenum. Has camera.
Contrast dye injected into ducts of the pancreas, and the bile ducts.

Can be used to do stuff during procedure, e.g. remove gallstones, place stents to keep narrowed ducts open

204
Q

Pancreatic cancer with obstructive jaundice. If staged as unresectable, what treatment?

A

ERCP and stent

205
Q

What’s a laparotomy?

A

A surgical procedure involving a surgical incision through the abdominal wall to gain access into the abdominal cavity.

206
Q

What’s whipples procedure removing? (Used for pancreatic cancer sometimes)

A

Like 1/3 of stomach, head of pancreas and lower end of bile duct and the duodenum.

207
Q

For removing the head of the pancreas… often we do whipples. That involves taking the stomach. What’s the procedure where you don’t have to take the stomach?

A

During the anastomoses at the post pyloric location

208
Q

The pacemaker to get the stomach to empty is located where?

A

In the pylorus

209
Q

How quickly would a man acute fluid collection turn into a pseudo cyst?

A

A few weeks

210
Q

How does alcohol cause acute pancreatitis?

A

Direct injury
Increased sensitivity to stimulation
Oxidation products (acetaldehyde)
Non-oxidative metabolism

211
Q

How can ERCP cause acute pancreatitis?

A

Increased pancreatic ductal pressure

212
Q

Symptoms of acute pancreatitis?
And signs?

A

Symptoms = abdominal pain, nausea, vomiting, collapse

Signs = pyrexia, dehydration, abdominal tenderness, circulatory failure

213
Q

What’s pyrexia again?

A

Fever

214
Q

Initial management of acute pancreatitis?

A

Analgesia
IV fluids
Resuscitate- support which ever organ is failing

215
Q

Most digestion happens in the small intestine, right?

A

Yes

216
Q

Digestion in the small intestine requires little fluid, true or falss

A

False

217
Q

Pancreatic lipase is involved in what, which happens via what

A

Absorption of glycerol and free fatty acids via lacteal and lymphatic system

218
Q

What breaks down carbs?

A

Pancreatic amylase- to disaccharides by brush border disaccharidase

219
Q

Why is there a low bacterial population in the stomach?

A

Because of digestive enzymes
Bile salts
Presence of IgA

220
Q

Signs of small bowel disease?

A

Signs of weight loss
Low or falling BMI

221
Q

Clubbing is a sign of what small bowel disease?

A

Coeliac disease
Crohn’s

222
Q

Dermatitis herpetiformis is a cutaneous manifestation of coeliac disease. What actually is it in layman’s terms?

A

Blistering
Intensely itchy
On scalp shoulders elbows and knees
It’s an IgA deposit in skin

223
Q

What’s happening in coeliac disease?

A

Gliadin, a component of gluten, is not broken down fully, and passes through the intestinal epithelial layer, triggering an immune response.

This results in chronic inflammation within the small bowel, damaging the epithelium and ultimately resulting in malabsorption

224
Q

Which immunoglobulin deficiency is a risk factor for coeliac disease?

A

IgA

225
Q

Do you have a trial of gluten free diet with coeliac disease?

A

No, not in terms of diagnosis

226
Q

That portion of gluten in coeliac disease binds to what, which we screen for?

A

HLA DQ2 and DQ8 screen

227
Q

What antibodies are diagnostic or of coeliac disease if strongly positive?

A

Anti-tTG antibodies
(And also total IgA count)

228
Q

If serology markers for coeliac disease is positive- like HLA DQ2, and DQ8, and Anti tTG antibodies, and total IgA count- what do we do next?

A

Take a duodenal biopsy to support diagnosis

229
Q

What 4 key changes are seen on duodenal biopsy with coeliac disease?

A

Presence of villous atrophy leading to a flat mucosa
Crypt cell hyperplasia
Intra-epithelial cell lymphocytosis
Inflammatory cell infiltration of the lamina propria

230
Q

HLA DQ2 or DQ8 status - does this confirm coeliac disease?

A

No
Useful to exclude as some of the general population are the same

231
Q

Is gliadin in rice and maize?

A

No

232
Q

Complications of coeliac disease?

A

Refractory coeliac disease
Small bowel lymphoma
Oesophageal carcinoma
Colin cancer
Small bowel adenocarcinoma

233
Q

True or false, coeliac disease is inflammatory and causes malabsorption

A

True

234
Q

What does whipples disease cause?

A

Malabsorption

235
Q

How common is colorectal cancer?

A

Second leading cause of cancer death in the western world

236
Q

Risk factors for colorectal cancer?

A

No obvious genetic component
Chronic IBD will pre-dispose, but only in a very small percentage of patients

Obesity
Smoking

Red meat

237
Q

How does risk for colorectal cancer change with cancer?

A

Increases with age

238
Q

Majority of colorectal cancers arise from what?

A

Pre-existing polyps, histologically adenomas
So we always treat polyps

239
Q

How does carcinoma develop from adenomas?

A

Activation of oncogenes
Loss of variety of tumour suppressive genes as well as defective DNA repair pathway which can lead to cell growth, proliferation and apoptosis

240
Q

Symptoms of colorectal cancer?

A

Rectal bleeding
Change in bowel habit especially loose stools
Anaemia due to blood loss
Patients may have a rectal or lower abdominal mass
Colonic obstruction if there is a stenosing tumour
Systemic symptoms of malignancy such as weight loss and anorexia

241
Q

Investigating anyone with suspected colorectal cancer?

A

Investigation of choice is colonoscopy
(During which we can take out polyps- therapeutic as well as diagnostic)

242
Q

Why do patients require a very strong laxative before a colonoscopy?

A

Requires to clear out the bowel in order to visualise the colon

Also, it can be uncomfortable advancing the colon scope around the large bowel, so patients are given sedation and analgesia

243
Q

What image for investigation of colorectal cancer?

A

CT colonoscopy
(Requires bowel preparation in order to be able to pick up small ones)

244
Q

What imaging is good for staging once colorectal cancer has been diagnosed?

A

CT scanning

245
Q

What is lynch syndrome?

A

Basically inherited error in DNA that puts you at 80% risk of colorectal cancer. Has GI related symptoms.

246
Q

Lynch syndrome is associated with what?

A

Early onset colorectal cancer

247
Q

Cancers associated with lynch syndrome are what side?

A

Right sided

248
Q

Is lynch syndrome associated with polyps beforehand?

A

No

249
Q

Patients who fulfil the Amsterdam criteria for lynch syndrome are offered what?

A

Genetic testing
Screening in the form of colonoscopies

250
Q

IBD is associated with colorectal cancer. Surveillance colonoscopy is offered how many years after diagnosis?

A

10 years

251
Q

If patients have an undetectable faecal immunoglobulin, then what is the chance of them having any significant colonic pathology?

A

Low chance

252
Q

What is PR bleeding?

A

Painless bleeding associated with bowel movement

253
Q

Why would someone who’s had an ileostomy become more easily dehydrated than anyone with a colon?

A

Because it’s the job of the colon to absorb water (and electrolytes)

254
Q

The production and absorption of what vitamins will be lost after an ileostomy?

A

Vitamins K and B

255
Q

Why would your immune system be weakened after an ileostomy?

A

The colon hosts the gut microbiota, which has a role in immune function and disease

256
Q

Describe the cross-section of the colon

A

Mucosa - surface epithelium, lamina propria, muscle layer
Submucosa (with nerves, arteries and veins)
Muscularis externa- longitudinal (plexus) and then circular
Serosa - visceral peritoneum

257
Q

What cells at the anus?

A

Squamous cell

258
Q

Mid guy is supplied by what artery

A

Superior mesenteric artery

259
Q

Which veins of the colon join together with the portal vein to drain through the liver?

A

The superior mesenteric vein
The inferior mesenteric vein
Splenic vein (from spleen, stomach Fundus, and part of the pancreas)

260
Q

Superior Vs inferior mesenteric vein - left or right drainage from colon?

A

Superior = right

261
Q

The vagus nerve supplies which part of the colon?

A

Ascending and transverse
Imagine it coming from the top

262
Q

Parasympathetic vagus to the bowel- where’s that from?

A

C 3 4 5

Remember ‘ 345 ‘ keeps the diaphragm alive

263
Q

Stool consistency could be as a result from central control. What does this affect, for the patient?

A

Continence

264
Q

How do we screen patients for colorectal cancer?

A

qFIT test.
Quantitive faecal immunochemical test

265
Q

What is a qFIT colorectal screening test?

A

Quantitive faecal immunochemical test. Get patients from age 50 to send in a sample of feces. - to test for blood in the poop. If patients have blood in the poop. Then = colonoscopy

266
Q

Why would a qFIT test show blood in the faeces, if you have colorectal cancer?

A

Tumour or polyp Invading blood vessels
Polyp irritated or damaged = ulcerations in the intestinal lining! Could lead to bleeding

267
Q

Does a positive qFIT mean colorectal cancer?

A

Not necessarily

268
Q

Treatment of hundreds of adenomas in FAP?

A

Surgical removal of entirety of bowel if need be.

269
Q

Polyp definition

A

A small growth, usually benign, protruding from a mucous membrane

270
Q

Most patients with abdominal rectal cancer will present with what?

A

Altered bowel habit, tending towards diarrhoea, and rectal bleeding

271
Q

When do patients of colorectal cancer tend to present with abdominal pain?

A

Later on usually

272
Q

Patients with black tarry stool- where are they bleeding from?

A

Upper aspect of their GI tract eg duodenum or the stomach

273
Q

Tenesmus is a symptom of rectal cancer. What is it?

A

Feeling like you’ve not completed your bowel motion

274
Q

Fatigue in rectal cancer is from what anaemia?

A

Iron deficiency anaemia

275
Q

Rectal bleeding for younger patient, especially with anal symptoms, is more likely what than malignancy:

A

Hemorrhoidal

276
Q

Colon Vs rectal cancer: treated as separate cuz respond differently to chemo. Which one skips chemo-radiotherapy, and goes straight to surgery?

A

Colon

277
Q

Surgery of rectal cancer- doesn’t just remove the rectum. What else is removed?

A

Mesorectum (contains lymph nodes)

278
Q

Why do we do pre op MRI for rectal cancer?

A

To see if tumour is eroding through mesorectal fascia

279
Q

Requirements of bowel anastomosis?

A

Tension free
Well perfused/ oxygenated
Clean surgical site

280
Q

Difference between ileostomy vs colonoscopy stoma?

A

Ileo = has spout to reduce amount of excoriation of the skin associated with the bowel content.

281
Q

Do you only remove the colon? What about the blood supply?

A

No we also remove the blood supply

282
Q

Why wouldn’t a patient vomit with a bowel obstruction?

A

If the ileocecal valve is competent

283
Q

No vomiting in bowel obstruction- we conclude that the ileocecal valve is competent. What other symptoms might I see

A

Abdominal pain
Constipation
Distension

284
Q

Why must we never let the sun rise or set on a bowel obstruction?

A

Because of the risk of perforation

285
Q

If large bowel obstruction isn’t cancer, what is it?

A

Diverticula’s disease
Or maybe ischaemia has tightened up vessels

286
Q

A hernia could cause small bowel obstruction true or false

A

True

287
Q

For a patient with bowel obstruction, why do we like to establish how haemodynamically stably they are?

A

They have lost a huge amount of fluid into their colon so are dehydrated

So use nasal gastric tube

288
Q

Why would drugs and analgesia be given via IV?

A

Because patients can’t absorb anything orally

289
Q

Why do bowel obstruction patients require antibiotics IV?

A

Just in case of perforation or bacterial translocation

290
Q

Investigation for coeliac disease?

A

Genetic testing for human leukocyte antigens (HLA-DQ2 and HLA-DQ8) can be used to rule out celiac disease.

291
Q

What’s waterbrash a symptom of? (Metallic taste and excessive saliva in mouth)

A

Gerd

292
Q

Heart burn and dental problems?

A

= GORD

293
Q

What genetic disease leads to unconjugated bilirubin?

A

Gilbert’s disease

294
Q

What is Murphy’s sign?

A
295
Q

Shoulder top pain could be referred pain from what area?

A

Gall bladder area

296
Q

What is diverticula?
(If inflamed, diverticulitis)

A

Mucosa blown out from the muscles
From when straining

297
Q

Typical presentation of diverticulitis

A

Guarding of muscles
Systemic symptoms -tachypnoea etc
Pain in left iliac fossa

Can have a rupture/perforation after inflammation

298
Q

How to treat diverticulitis?

A

Antibiotics.

299
Q

Why would the cecum perforate with the presence of a sigmoid tumour?

A

Chyme can’t go anywhere when a sigmoid tumour blocks. Bowel gets bigger and bigger until the cecum perforates.

300
Q

what happens to the peritoneum after perforatiom of the bowel?

A

faecal contamination .

301
Q

pain out of proportion of the clinical signs suggests what

A

ischaemia or perforation

302
Q

why would you give someone with a rectal tumour, an ileostomy rather than straight surgical removal?

A

so they can get better enough after the obstruction to be well enough for chemo or radiotherapy, to reduce size of tumour, to make the surgical removal more successful in the end.

303
Q

What does the anorectum require to avoid incontinemce?

A

a ‘pelvic floor’
rectal compliance
intact pelvic neurology

304
Q

How many folds in the rectum?

A

3
superior
middle
inferior

305
Q

what cell type in the rectum?

A

squamous

306
Q

Most common pathology of the anorectum?

A

haemorrhoids- becomes pathological after hyperplasia of tissue cushion surrounding lower rectum

307
Q

commonest cause of haemorrhoids in the rectum

A

straining eg due to constipation

308
Q

haemorrhoid definition

A

a swollen vein or group of veins in the region of the anus, usually painless.

309
Q

commonest treatment for haemorrhoids of the rectum?

A

rubber band ligation
or surgical:
HALO
hemorrhoid artery ligation operation

310
Q

whats the dentate line

A

divides upper two, and lower third of the anal canal. each supplied by different nerve for control of defecation and continence.

311
Q

splatter in the pan blood vs wiping blood

A

splatter in the pan = haemorrhoid
vs
wiping blood = fissure related bleeding, can be quite profuse.

312
Q

hallmark symptom of fissure bleeding is what?

A

pain like passing glass splinters

313
Q

commonest cause of fissure in the anus/rectum?

A

tear after passing hard faeces due to constipation

314
Q

management of anal fissure

A

Address underlying cause
Give patient GTN ointment

(very difficult to treat).

315
Q

what does GTN ointment do to a fissure?

A

GTN causes a relaxation of one of the muscles and is also associated with increased blood supply to the area of the fissure, thereby allowing the fissure to heal.

injection of botox does the same

316
Q

whats a fissure ectomy?

A

cleaning up fissure and straightening edges

317
Q

How to treat a perianal abscess? (Which will have excruciating pain).

A

Incision and drainage
Antibiotics if septic

318
Q

A fistula is an abnormal connection between which two surfaces?

A

Epithelium

319
Q

Abscess definition (vs ulcer)

A

Abscess = swollen area with build up of pus (closed off)
Ulcer = open

320
Q

Most common cause of an abscess?

A

Mainly bacterial

321
Q

Most common cause of an anal fissure?

A

Constipation

322
Q

why wouldn’t you lay open a fistula in women?There

A

Their muscle walls are too thin, so it would render them incontinent.

323
Q

Why would you lay open a fistula at all, in a woman?

A

Thin muscles in anus, could lead to damaging sphincter and therefore incontinence.

324
Q

causes of pelvic floor dysfunction

A

Delivering a baby. or other causes like surgery, abuse, perianal sepsis, Low Anterior Resection Syndrome, fistula

325
Q

'’treat’’ pelvic floor dysfunction how?

A

with physiotherapy

326
Q

what actually is diarrhoea? Bc it can be one of two things….

A

Difficulty passing, or reduced frequency of doing do.

327
Q

4 biggest reasons for chronic constipation

A

dietary (commonest)
drugs
organic
functional e.g. slow transit

328
Q

what affect on the bowels could anti-depressants have?

A

could cause constipation.

329
Q

diuretics could cause constipation, true or false

A

true
cuz of dehydration?

330
Q

treat chronic constipation how- first level initial stuff

A

exclude sinister pathologies- constipation is a symptom not a disease.

as the most common reason is just diet though, the ‘treatment’ is really just intense diet modification- veggies/lots of fibre and caffiene, hydration (of actual water) and biofeedback for learning/relearning toilet posture.

331
Q

next level treatment of constipation???

A

irrigation
or
surgery

332
Q

example of surgery for chronic constipation?

A

subtotal colectomy with end ileostomy

333
Q

4 reasons for faecal incontinence?

A

passive
urge
mixed
overflow

334
Q

reason for passive faecal incontinence?

A

internal sphincter defect

335
Q

reason for urge faecal incontinence?

A

rectal pathology, functional

336
Q

reason for faecal incontinence that is both urge and passive?

A

prolapse

337
Q

reason for overflow faecal incontinence?

A

constipation

338
Q

how do we assess faecal incontinence?

A

1) detailed history of whether it is

339
Q

Epigastric pain, relieved by eating. What is it?

A

It must be peptic ulcer

340
Q

How would a GP test for a peptic ulcer, potentially caused by h.pylori, in out of hours?

A

do a urea breath test
because h. pylori releases urease enzyme to maintain the alkaline environment it enjoys.

341
Q

why would a peptic ulcer be relieved by eating?

A

1) coating effect of food as an ulcer.
2) mucus and bicarbonate release from the stomach the released to protect stomach lining.

342
Q

why would the duodenum be the place that most peptic ulcers occur?

A

h pylori enjoys the slightly more alkaline environment of the duodenum.

343
Q

You’re a GP in a medical practice, your last patient comes in, a 61 year old gent with iron deficiency. You send him home with iron tablets. Next morning, your colleagues are extremely angry with you. Why?

A

Because iron deficiency at that age is a red flag. Send him in for an urgent endoscopy.

344
Q

Working in the hospital. Clinician asks you to grab a score chart off a printer for a patient with an upper GI bleed. What score chart will this likely be? And what is this score chart for?

A

Rockall Score.
To predict re-bleeding and mortality rates. Used for a patient

345
Q

Is the rockall score pre or post endoscopy?

A

not sure

346
Q

A gentleman was seen this morning by his GP, presenting with abdominal distension, acute abdominal pain and vomiting.
After an abdominal examination, the GP undertook which investigation and why?

A

Suspected small bowel obstruction, therefore did a CT abdomen/pelvis.

347
Q

CT abdomen/pelvis is good for which GI conditions?

A

small bowel obstruction
IBD
malignancy
hernias

348
Q

A gentleman was seen this morning by his GP, presenting with abdominal distension, acute abdominal pain and vomiting.
After an abdominal examination, the GP undertook abdominal/pelvic to confirm the diagnosis as being small bowel obstruction. What’s the FIRST INSTANCE management- if no sign of ischaemia or strangulation?

A

wide NG tube, with IV fluids, nil by mouth, analgesia

349
Q

Man with small bowel obstruction. No sign of strangulation or hernias, so we started on initial management of: wide NG tube, with IV fluids, nil by mouth, analgesia. That doesn’t appear to be working: what next?

A

contrast water soluble barium study.
Then do X-Ray. If contrast has not passed through to the colon, we’ll have an operation

350
Q

Man with bowel obstruction can’t pass the water soluble barium contrast after 6 hours. We gotta do surgery. What surgery have we gotta do?

A

emergency laparotomy

351
Q

Man with small bowel obstruction, given IV fluids, NG tube etc. Watch and wait and the barium contrast hasn’t passed after 6 hours. He becomes increasingly tachycardic, pain gets worse, develops a fever. What complication might have occurred?

A

Ischaemic bowel.

352
Q

What’s anal manometry?

A

a medical procedure used to assess the function and strength of the muscles in the anal canal.
A thin, flexible catheter with pressure sensors, called a manometry probe, is inserted into the rectum and positioned in the anal canal. Has balloon at the end.

353
Q

What’s RAIR?

A

Recto-anal Inhibitory Reflex.
Basically when rectum fills with stool, pressure will eventually reach threshold, receptors in wall react. Causes internal anal sphincter to relax. so that reflex is what allows stool from rectum into anal canal.

354
Q

what image modality might we use to drain abscesses???

A

don’t really know
But we’d use image guided percutaneous drainage -ultrasound or CT

NB there is also such thing as image guided biopsies

355
Q

The deep part of the external anal sphincter is not seen in which sex?

A

In females

356
Q

When might you need an anal bulking agent?

A

For passive faecal incontinence

357
Q

Young people with IBD may need recurrent imaging, but we want to avoid radiation. What would you use?

A

frequent MRI

358
Q

We get the patient drinking a reasonably large quantity of an osmotic liquid before MRI. Why?

A

To distend the small bowel.

359
Q
A

YEAR 2 GI (7 decks)

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