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GASTROINTESTINAL > Week 8 > Flashcards

Week 8 Flashcards

1
Q

What 5 things are important to consider in assessing the severity of liver cirrhosis?

A 
Encephalopathy 
Ascites 
Bilirubin 
Albumin 
Prothrombin time
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2
Q

Loss of haustral markings in the distal part of the bowel suggests which disease?

A

Ulcerative Colitis

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3
Q

Which test is the single most important factor for considering suitability for a liver transplant?

A

Arterial pH

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4
Q

Behavioural changes, clumsiness and excess salivation could indicated which condition?

A

Wilson’s Disease

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5
Q

What is Wilson’s Disease treated with?

A

Penicillamine

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6
Q

How would achalasia present differently to oesophageal malignancy in terms of dysphagia?

A

Achalasia would present with dysphagia to both liquids and solids from the outset whereas oesophageal malignancy would involve progressive symptoms with dysphagia first to solids and then to liquids.

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7
Q

How are alcohol units calculated?

A

(Volume (ml) x ABV) Divided by 1000

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8
Q

What is the most likely cause of an elevated ALT and AST in the 10,000s?

A

Paracetamol overdose

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9
Q

Can pain be felt above or below the dentate line in the anal canal?

A

Anything below the dentate line will be very painful but anything above will not cause pain as there are no sensory fibres to this area

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10
Q

What are haemorrhoids?

A

Disrupted and enlarged vascular cushions in the lower rectum and the anal canal

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11
Q

What percentage of the population will have symptomatic haemorrhoids at some point in their life?

A

10%

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12
Q

What is the classical position of the haemorrhoids when the patient is in the lithotomy position and what does this correspond to?

A

The position corresponds to the branches of the superior haemorrhoids artery at 3, 7 and 11 o’clock

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13
Q

What can cause haemorrhoids?

A

***Constipation and prolonged straining
Congestion from a pelvic tumour
Pregnancy
Portal hypertension

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14
Q

How might haemorrhoids present?

A

Painless bleeding - bright red (on the paper/ in the pan)
Perianal itchiness
Anaemia

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15
Q

Describe the classification of haemorrhoids

A

1st degree - remain in the rectum
2nd degree - protrude through the rectum on defecation but then reduce
3rd degree - ^ &require reduction
4th degree - remain persistently prolapsed

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16
Q

What investigations might be done for haemorrhoids?

A 
Abdominal exam (to rule out other causes) 
PR exam 
Proctoscopy (to visualise internal haemorrhoids) 
Flexible sigmoidoscopy
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17
Q

How would haemorrhoids be managed/ treated?

A 
Topical analgesics
Stool softeners 
Topical steroids 
Sclerotherapy 
Rubber band ligation 
Haemorrhoidectomy 
HALO/ THD procedure
  • For acutely thrombosis/ painful haemorrhoids
  • ice compressions and topical GTN or diltiazem to reduce sphincter spasm
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18
Q

What is a rectal prolapse? What is the difference between a type 1 and type 2 prolapse?

A

A rectal prolapse is a protruding mass from the anus, especially during defecation
Type 1 - partial - just mucosal layers
Type 2 - complete - transmural / all layers

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19
Q

How would a rectal prolapse present?

A

Protruding mass
Bleeding and mucus per rectum
Poor anal tone on examination

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20
Q

How would a rectal prolapse be managed? consider management of both a complete and incomplete prolapse

A 
Incomplete 
- Dietary advice and treatment of constipation 
Complete 
- Bulking agent 
- Delform's procedure
- Perineal rectopexy 
- Abdominal rectopexy 
- Anterior resection
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21
Q

What are some of the causes of rectal prolapse?

A

Lax sphincter
Prolonged straining
Chronic neurological and psychological disorders

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22
Q

What is an anal fissure? Where do these most commonly occur?

A

A tear in the anal margin due to the massage of a constipated stool
- Usually midline posteriorly but can be anterior

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23
Q

What is the typical presentation of an anal fissure? Which age group are they most common in?

A
  • Sharp and severe pain on defecation after constipation
  • pain may last for up to half an hour and becomes dull in character
  • Bright red rectal bleeding
  • Most common in young people - very rare in the elderly
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24
Q

How are anal fissure managed?

A
  • Stool softeners and dietary advice
  • Topical diltiazem or GTN ointment (pharmacological sphyncterotomy)
  • Sphyncterotomy
  • Botox injection
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25
Q

What is meant by ‘Fistula in Ano’ ?

A

An abnormal communication between two epithelial surfaces - the anal canal and the peri-anal skin

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26
Q

What is the most common cause of fistula-in-ano? State the other less common causes

A

Inadequate treatment of an anorectal abscess

Crohn’s
Carcinoma
TB

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27
Q

How might Fistula-In-Ano present?

A

Pain
Bright red PR bleeding
Incontinence of flatus/ stool

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28
Q

How would fistula-in-ano be investigated?

A

EUA of anorectum
Rigid sigmoidoscopy and proctoscopy
Flexible sigmoidoscopy
MRI

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29
Q

How is fistula-in- and managed?

A 
Laying it open (fistulotomy) 
Insertion of Seton suture
LIFT procedure 
Glue/ permacol 
Defunctioning colostomy
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30
Q

List 3 perioperative complications of GI surgery

A

Ileus
Anastamotic Dehiscence
Adhesions

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31
Q

What is ileus and how would this present post GI surgery?

A

Paralysis of intestinal motility

  • Vomiting
  • Abdominal distension
  • Absent bowel sounds
  • Dehydration
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32
Q

What is anastomotic dehiscence? State three types of this which could possibly occur post GI surgery

A

Breakdown of anastomosis

  • intestinal
  • vascular
  • urological
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33
Q

How might anastomotic dehiscence present post surgery?

A 
Peritonitis 
Abscess 
Fistula 
Bleeding /haematoma 
Leakage of urine / urinoma
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34
Q

Describe adhesions and how they occur

A

Handling of the bowels in surgery can cause inflammation which causes formation of fibrous tissue which tethers the bowel to itself or to adjacent structures

Can also occur;

  • Due to inflammatory conditions e.g Crohn’s
  • Secondary to infection
  • Due to ischaemia
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35
Q

Post operative adhesions can cause small bowel obstruction. How does this present?

A

Vomiting
Chronic pain
Distension
Constipation

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36
Q

List some of the symptoms of intestinal obstruction

A

Constipation
Distension
Pain
Vomiting

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37
Q

Vomitus can give a clue as to the level of the obstruction within the bowels.
Describe the appearance of vomitus that might come from;
- Gastric outlet obstruction
- Upper small bowel obstruction
- Distal obstruction

A
  • Gastric outlet obstruction
  • Semi-digested food
  • Upper small bowel obstruction
  • Copius bile stained fluid
  • Distal obstruction
  • Thick, brown and foul smelling
38
Q

Describe the two different types of pain bowel obstruction can cause and why they occur

A

Visceral pain - Due to stretch receptors when the bowel is distended
Colicky pain - Due to peristalsis trying to overcome the obstruction

39
Q

What is meant by absolute constipation?

A

Neither faeces of flatus is passed rectally

40
Q

Describe the difference in the situation if the large bowel is obstructed and the ileocaecal valve is competent or if the valve is incompetent

A
  • Competent ileocaecal valve
  • The thin walled caecum becomes distended - there can be no back flow into the small bowel so the caecum may rupture
  • Incompetent ileocaecal valve
  • Not ideal but it will actually save the patient’s life. There can be back flow into the small bowel which prevents mass build up in the caecum - the small bowel will become distended - lower risk of rupture
41
Q

What can chronic incomplete obstruction do to the muscle of the proximal bowel wall?

A

Cause hypertrophy of the muscle of the proximal bowel wall

42
Q

What are some of the physical signs of intestinal obstruction?

A

Dehydration
- Dry mouth and loss of elasticity of the skin

Abdominal Distension

Obstructing hernia

High pitched/ tinkling bowel sounds

Resonant abdomen due to gaseous distension

Palpable abdominal mass

Visible peristalsis

43
Q

What investigations should be done for bowel obstruction?

A

Supine Abdominal X-ray

CT Scan

44
Q

How can small bowel be distinguished form large bowel on an abdominal X-ray?

A

Small bowel is usually central and has valvular coniventes - lines that transverse the bowel

Large bowel is usually within its anatomical boundaries and has haustra - lines which only go partly across the bowel

45
Q

How is obstruction managed?

A

Nil by mouth
IV cannula - fluids and electrolytes
Nasogastric tube to decompress the stomach

46
Q

List some of the causes of mechanical bowel obstruction?

A 
Volvulus 
Adhesions and bands 
Tumour 
Intussusception 
Bolus obstruction 
Inflammatory strictures 
Hernias
47
Q

What are some of the causes of adhesions or bands which can cause bowel obstruction?

A

Congenital
Previous abdominal surgery
Peritonitis

48
Q

Which two diseases can cause inflammatory strictures in the GI tract?

A

Crohn’s disease

Diverticular disease

49
Q

List 4 different types of bolus obstructions which can cause obstruction of the bowel

A

Food bolus
Impacted faeces
Impacted gallstones
Trichobezoar

50
Q

What is meant by Trichobezoar?

A

Hair balls

51
Q

What is meant by intussusception?

A

When a segment of the bowel wall becomes telescoped into the segment distal to it

52
Q

What can initiate intussusception?

A

Mass in the bowel wall

  • enlarged lymph tissues
  • tumours
53
Q

Which age group is intussusception most common in?

A

Children

54
Q

What is meant by bowel strangulation?

A

When a segment of the bowel becomes trapped, obstructing venous return

55
Q

Adynamic bowel obstruction is when there is no actual physical obstruction, but the bowel behaves as if there is. State two forms of adynamic bowel obstruction

A

Pseudo-obstruction

Paralytic Ileus

56
Q

What is meant by paralytic Ileus?

A

There is disruption of the normal propulsive activity in the GI tract due to failure of peristalsis

57
Q

What are the risk factors for paralytic ileus?

A

Recent GI surgery
Inflammation with peritonitis
Diabetic keto-acidosis

58
Q

What is meant by pseudo-obstruction?

A

Acute dilation of the colon in the absence of physical obstruction

59
Q

What are the risk factors for pseudo-obstruction?

A

Hip replacement surgery
Coronary artery bypass grafts
Pneumonia
Frail and elderly patients

60
Q

What is the definition of a hernia?

A

A protrusion of a viscus or part of a viscus through the wall that is designed to contain it

61
Q

What are the 3 layers which a hernia is composed of?

A
  • A sac (peritoneum)
  • Coverings of the sac
  • The contents of the hernia (e.g small bowel/ momentum e.t.c)
62
Q

List some of the types of hernias

A 
Inguinal 
Femoral 
Epigastric 
Paraumbilical 
Incisional 
Parastomal
63
Q

Which two types of hernia are classified as groin hernias?

A

Inguinal

Femoral

64
Q

Inguinal hernias are much more common in men - what is the reason for this?

A

The testicles pass through the inguinal canal during development meaning the canal is much wider in males - making them more susceptible

65
Q

Who get femoral hernias?

A

Elderly women/ women who have had several children

66
Q 
The inguinal ring has the following; 
- Posterior wall 
- Anterior wall 
- Floor 
- Roof
What structures make up these areas?
A

Posterior wall = transversals fascia

Anterior wall = aponeurosis of external oblique, internal oblique

Floor =
Inguinal ligament and the lacunar ligament

Roof =
Transversalis fascia
Internal oblique
Transversus abdominus

67
Q

What is meant by an irreducible hernia?

A

The hernial sac can’t be pushed back to its right place in the abdominal cavity

68
Q

What is meant by incarceration of a hernia?

A

The contents of the hernial sac are stuck inside by adhesions

69
Q

What is meant by a strangulated hernia?

A

Ischaemia has occurred

70
Q

Where anatomically are femoral hernias found?

A

Below and lateral to the pubic tubercle

71
Q

How are femoral hernias managed?

A

They often present acutely and require an op more urgently than inguinal hernias do
The procedures;
‘Lockwood’s’ (low approach)
‘McEvedy’s (high approach)

72
Q

What are some of the risk factors for inguinal hernias?

A 
Male 
Increasing age 
Obesity 
Chronic cough 
Previous hernia
73
Q

Where anatomically are inguinal hernias found?

A

Above and medial to the pubic tubercle

74
Q

What is the difference between a direct and an indirect inguinal hernia?

A

A direct inguinal hernia is medial to the inferior epigastric vessels - it herniates through a weakness in the posterior wall of the inguinal canal

An indirect hernia is lateral to the inferior epigastric vessels - the abdominal contents protrude trough the deep inguinal ring

75
Q

Are inguinal hernias more common on the left or the right side?

A

More common on the right than on the left

76
Q

How are inguinal hernias managed?

A

If asymptomatic - don’t need management
Open hernia surgery
Laparoscopic surgery

77
Q

Laparoscopic surgery is now the preferred treatment than open surgery for inguinal hernias. What are its pros and cons?

A 
PROS 
- Doesn't leave patients with chronic pain 
- Lower rates of infection post op 
- Faster recovery 
CONS
- Harder surgery 
- Isn't done for emergencies
78
Q

What are some of the possible complications of surgery for inguinal hernias?

A 
Recurrence 
Urinary retention 
Haematoma 
Chronic pain / numbness 
Wound infection 
Testicular atrophy
79
Q

Why do epigastric hernias occur? Are they more common in males or females?

A

Occur due to a defect in the linea alba between the xiphoid process and the umbilicus
More common in males

80
Q

What are some of the risk factors for paraumbilical hernias?

A

Obesity
Pregnancy
Ascites

81
Q

Where do incisional hernias occur?

A

At the site of a previous abdominal incision

82
Q

What are the common paediatric hernias?

A

Umbilical and inguinal hernias

83
Q

What investigations can be done for pancreatitis?

A

FBC

Elevated amylase

Ultrasound

ERECT CXR ( looks for perforation)

CT

84
Q

Describe the typical presentation of appendicitis

A

Central abdominal pain which later localises to the RIF

- fever and elevated inflammatory markers are possible

85
Q

What investigations should be done for appendicitis?

A

Ultrasound

86
Q

Describe the possible presentation of diverticulitis and how it might be investigated

A

Lower abdominal pain classically in the LIF which can present with diarrhoea and PR bleeding +elevated inflammatory markers
- CT to investigate

87
Q

How does cholecystitis present and how would it be investigated?

A

RUQ pain - biliary colic - exaggerated by eating +deranged LFTs
- Investigated with ultrasound and MRCP/ERCP

88
Q

How is haematemesis investigated?

A

Endoscopy - intervention or biopsy can be done with this

CT with IV contrast - angiography or intervention can be done

89
Q

What investigations should be done for dysphagia?

A

Endoscopy

Barium contrast

90
Q

What investigations might be done for a patient with a change in bowel habit?

A

PR exam
Flexible sigmoidoscopy
CT virtual colonography

91
Q

What investigations should be done for jaundice?

A

Ultrasound
MRCP/ERCP
CT

92
Q

What investigation should be done for small bowel ischaemia?

A

CT angiogram - looks at the patency of the vessels

GASTROINTESTINAL (13 decks)

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