1
Q
Where is Vitamin C found?
A
- tomatoes
- citrus fruits
- cauliflower, broccoli, spinach, sprouts
2
Q
What is the pathophysiology of low Vit C?
A
- impaired collagen synthesis
- weakened connective tissue
3
Q
What are symptoms of Vit C deficiency?
A
- gingivitis
- easy bruising
- arthralgia
- poor wound healing
4
Q
What is the management of life-threatening C. difficile infection?
A
- oral vancomycin
- IV metronidazole
- best bioavailability
5
Q
What is the difference between cholecystitis and cholangitis?
A
- cholecystitis: inflammation of the gallbladder
- cholangitis: inflammation of the bile ducts
6
Q
Describe the path of biliary outflow from the liver to the duodenum
A
- R and L hepatic ducts > common hepatic duct
- cystic duct + CHD = common bile duct
- CBD joins pancreatic duct to form ampulla of Vater controlled by Sphincter of Oddi
7
Q
What is acute cholangitis?
A
- infection and inflammation in the bile ducts
- caused by obstruction or infection from ERCP
8
Q
Which organisms most commonly cause acute cholangitis?
A
- E. coli
- Klebsiella
- Enterococcus
9
Q
What is the pathophysiology of acute cholangitis?
A
- biliary system obstruction
- bile flow slows/stops
- causes bile to thicken
- provides ideal bacterial growth medium
10
Q
What are risk factors for acute cholangitis?
A
- gallstone disease e.g. Mirizzi syndrome or choledocholithiasis
- tumours
- PSC
- strictures
11
Q
What is Charcot’s triad for acute cholangitis?
A
- RUQ pain
- fever
- jaundice
12
Q
What is Reynold’s pentad for acute cholangitis?
A
In addition to RUQ, fever, jaundice:
- hypotension
- confusion
13
Q
How is acute cholangitis diagnosed?
A
- 1st line: transabdo USS
- CT with contrast if USS negative
- MRCP
14
Q
How is acute cholangitis managed?
A
- NBM
- IV fluids
- blood cultures and IV antibiotics
- ERCP after 24-48h + stent
- PTC and biliary drain if ERCP unsuccessful
15
Q
What bloods may be seen in acute cholangitis?
A
- raised bilirubin and ALP
- raised WCC
- raised CRP
16
Q
What are the causes of pancreatitis?
A
I - idiopathic
G - gallstones
E - ethanol (alcohol)
T - trauma
S - steroids
M - mumps
A - autoimmune
S - scorpion sting
H - hyperlipidaemia, hypercalcaemia, hypothermia
E - ERCP
D - drugs
17
Q
How do gallstones cause pancreatitis?
A
- get trapped at ampulla of Vater
- block flow of bile and pancreatic juice into duodenum
- reflux of bile and prevention of pancreatic enzyme secretion > inflammation
18
Q
What drugs cause pancreatitis?
A
- azathioprine
- mesalazine
- bendroflumethazide, furosemide
- steroids
- sodium valproate
19
Q
How does pancreatitis present?
A
- severe epigastric pain radiating through to back
- vomiting
- decreased appetite
20
Q
What may be seen on examination of pancreatitis?
A
- fever
- epigastric tenderness
- abdo distention
- ileus
- discolouration
21
Q
What is Cullen’s sign?
A
- periumbilical discolouration
- associated with acute pancreatitis
22
Q
What is Grey-Turner’s sign?
A
- flank discolouration
- associated with acute pancreatitis
23
Q
What is Purtscher’s retinopathy?
A
- ischaemic retinopathy which may cause temporary or permanent blindness
- associated with acute pancreatitis
24
Q
What is seen on bloods when investigating pancreatitis?
A
- amylase raised 3x
- lipase raised 3x (more sensitive and specific)
25
What factors are used to calculate the Glasgow score?
- P – PaO2 < 8 KPa
- A – Age > 55
- N – Neutrophils (WBC > 15)
- C – Calcium < 2
- R – uRea >16
- E – Enzymes (LDH > 600 or AST/ALT >200)
- A – Albumin < 32
- S – Sugar (Glucose >10)
26
What bloods indicate severe pancreatitis?
- hypocalcaemia
- hyperglycaemia
- neutrophilia
- raised LDH and AST
27
How is acute pancreatitis managed?
- ABCDE
- IV fluids and analgesia
- monitoring and treatment of complications
- antibiotics if required
- enteral feeding if required
28
What are the most common causes of acute pancreatitis?
- alcohol
- gallstones
29
What is the pathophysiology of acute pancreatitis?
- autodigestion of pancreatic tissue
- leads to necrosis
30
What are risk factors for pancreatitis?
- male
- age
- smoking
- obesity
31
What is specific management of gallstone pancreatitis?
- ERCP
- cholecystectomy
32
What are pancreatic pseudocysts?
- collections of fluid not surrounded by epithelium
- occur 2-4 weeks after acute pancreatitis
- elevated amylase
- 50% need drainage/excision
33
What is pancreatic necrosis and how is it managed if infected vs uninfected?
- complication of acute pancreatitis
- involves pancreatic parenchyma and surrounding fat
- if uninfected, avoid surgery
- infected may need necrosectomy
34
How do pancreatic abscesses occur?
- infected pseudocyst
- causes intraabdominal collection of pus
- drainage to treat
35
What are the causes of chronic pancreatitis?
- alcohol excess
- cystic fibrosis
- haemochromatosis
- ductal obstruction
36
What is the characteristic of the pain in chronic pancreatitis?
- epigastric pain radiating to the back
- worse in 15-30 mins following a meal
- relieved by sitting forward
37
Presentation of chronic pancreatitis other than pain and how long after the pain it presents
- steatorrhoea: pancreatic insufficiency (5-25yrs)
- diabetes (20 years)
38
How is chronic pancreatitis investigated?
- abdo XR: pancreatic calcification
- CT: same but higher sensitivity
- faecal elastase
39
How is chronic pancreatitis treated?
- pancreatic enzyme supplements
- analgesia
40
What are the 3 steps in the progression of alcoholic liver disease?
1. hepatic steatosis: drinking causes a buildup of fat which is reversible
2. alcoholic hepatitis: drinking over a long period/binging causes inflammation
3. cirrhosis: liver is made up of more scar tissue than healthy tissue. irreversible
41
What is the presentation of alcohol related liver disease?
- abdo pain
- hepatomegaly
- haematemesis
- jaundice
- splenomegaly
42
What are the LFTs seen in alcoholic liver disease? (GGT and AST:ALT ratio)
What level is seen in acute alcoholic hepatitis?
- elevated GGT
- AST:ALT ratio >2
- AST:ALT >3
43
What is the management for alcoholic hepatitis?
- glucocorticoids: prednisolone
- Maddrey's discriminant function (DF) used to calculate
- uses PT and bilirubin
44
What is the pathophysiology and causes behind peptic ulcers and which type are most common?
- occurs from breakdown of protective mucosal layer/ inc in stomach acid
- broken down by medications, H. pylori
- stomach acid inc by: stress, alcohol, caffeine, smoking, spicy food
- duodenal more common than gastric
45
What is the most common cause of peptic ulcer disease?
- H. pylori
46
Which drugs put patients at risk of peptic ulcers?
- NSAIDs
- corticosteroids
- SSRIs
- bisphosphonates
47
What is Zollinger-Ellison syndrome and where are they found?
- neuroendocrine tumour produces gastrin
- causes high gastric secretion of HCl
- found in duodenum and pancreas
48
What are features of Zollinger-Ellison syndrome?
- gastroduodenal ulcers
- diarrhoea
- malabsorption
- abdo pain and GORD
49
How is Zollinger-Ellison syndrome diagnosed?
- fasting gastrin levels
- gastric pH
- secretin stimulation test
50
How do peptic ulcers present?
- epigastric discomfort/pain
- nausea and vomiting
- dyspepsia
- coffee ground vomiting and melaena
- iron deficiency anaemia
51
How do duodenal and gastric ulcers differ in their presentation?
- duodenal: epigastric pain when hungry, relieved by eating
- gastric: epigastric pain worsened by eating
52
How are peptic ulcers investigated?
- H.pylori: urea breath test or stool antigen test
- if red flags: OGD + biopsy
53
What are the red flag criteria for urgent endoscopy referral?
- new onset dysphagia
- aged >55 with weight loss, upper abdo pain, reflux or dyspepsia
- new onset dyspepsia unresponsive to PPI treatment
54
What are the complications of peptic ulcers?
- bleeding
- perforation
- scarring and strictures leading to pyloric stenosis
55
How is peptic ulcer disease managed?
- lifestyle advice
- PPI for 4-6 weeks then reassess
56
What is triple therapy for H. pylori and how long does treatment last?
- PPI
- oral amoxicillin
- clarithromycin/metronidazole
- 7 days
57
What is triple therapy for H. pylori if penicillin allergic?
- PPI
- metronidazole
- clarithromycin
58
What is the presentation of perforation secondary to peptic ulcer disease?
- epigastric pain > generalised
- syncope
59
How is perforation secondary to peptic ulcer disease investigated?
- erect chest X-Ray
- shows free air under diaphragm
60
From which artery does bleeding tend to occur in peptic ulcer disease?
- gastroduodenal artery
61
How does bleeding as a complication of peptic ulcer disease present?
- haematenesis
- melaena
- hypotension and tachycardia
62
How is (severe) bleeding as a complication of peptic ulcer disease managed?
- ABC
- IV PPI
- 1st line: endoscopic intervention
- if endoscopy fails: urgent angiography and embolisation or surgery
63
What type of bacteria is H. pylori?
- gram negative
64
What is the pathophysiology of H. pylori?
- burrows into mucosal lining to reach epithelial cells
- secretes urease > urea converted to ammonia which leads to alkinisation and increased bacterial survival
- releases cytotixins that disrupt gastric mucosa
65
Which other conditions is H. pylori associated with?
- peptic ulcer disease
- gastric cancer
- B cell lymphoma
- atrophic gastritis
66
What is gastritis?
- gastric mucosal inflammation
67
What are types of gastritis?
- H. pylori infection
- erosive gastritis
- stress
- autoimmune
- phlegmonous
68
What are features of gastritis?
- nausea and vomiting
- anorexia
- abdo pain
- dyspepsia
69
What is achalasia?
- failure of oesophageal peristalsis
- failure of relaxation of the lower oesophageal sphincter
70
What is the pathophysiology of achalasia?
- degenerative loss of ganglia from Auerbach's plexus (myenteric)
- LOS contracted and oesophagus dilated
71
What are features of achalasia?
- dysphagia of liquids and solids
- heartburn
- regurg of food: cough, aspiration pneumonia
72
What is the epidemiology of achalasia?
- equally in men and women
- presents in middle age
73
What investigation are done for achalasia?
- oesophageal manometry
- barium swallow
- CXR
74
What is seen on oesophageal manometry in achalasia?
- excessive lower oesophageal tone which doesn't relax on swallow
75
What is seen on barium swallow in achalasia?
- grossly expanded oesophagus
- fluid level
- bird's beak
76
What is seen on CXR in achalasia?
- wide mediastinum
- fluid level
77
How is achalasia treated?
- pneumatic (balloon) dilation
- surgical: Heller cardiomyotomy
- if high surgical risk: Botox injection
78
What is the epidemiology of gastric cancer?
- older (half patients are >75)
- male (2:1) predominance
79
What is the most prevalent type of gastric cancer and from where does it arise?
- adenocarcinoma
- glandular epithelium of stomach
80
What are risk factors for gastric cancer?
- H. pylori (inflammation > metaplasia > dysplasia)
- pernicious anaemia
- atrophic gastritis
- diet: salt and nitrates
- smoking
- Japanese/Chinese ethnicity
81
What are features of gastric cancer?
- vague abdo pain: epigastric
- can present as dyspepsia
- weight loss and anorexia
- n+v
- dysphagia
82
Which lymph nodes may gastric cancer spread to?
- Virchow's: left supraclavicular
- Sister Mary Joseph: periumbilical
83
What investigations may be done to diagnose gastric cancer and what is seen?
- OGD with biopsy
- signet ring cells - higher number = worse prognosis
84
What investigations may be done to stage gastric cancer?
- CT CAP
- endoscopic USS
- PET scan
85
What is the surgical management of gastric cancer?
- endoscopic mucosal resection
- partial or total gastrectomy
86
What is small bowel obstruction?
- mechanical blockage of bowel
- form of intestinal failure
- inability of gut to absorb necessary water, macronutrients and electrolytes
87
What is the aetiology of small bowel obstruction?
- adhesions
- hernia
- cancer
88
How does bowel obstruction present?
- diffuse, central abdo pain
- green bilious vomiting
- abdo distention
- tinkling bowel sounds (early)
- constipation and lack of flatulence
89
Which bloods are used to investigate small bowel obstruction?
- FBC: shows anaemia if cancer
- U&E
- Lactate raised - bowel ischaemia
- metabolic alkalosis
90
What imaging is used in small bowel obstruction and what does it show?
- CT: gold
- abdo X-ray: distended loops with fluid levels
91
Why is contrast CT useful for small bowel obstruction?
- localises site of obstruction
- shows ischaemia and if intervention is required immediately
92
How is small bowel obstruction treated?
- drip and suck
- IV fluids
- nil by mouth
- NG tube with free drainage
- IV analgesia for pain
- antiemetics
- nutrition: may need parenteral feed
93
What is the most common complication of small bowel obstruction?
- renal failure
94
How can you tell the difference between small and large bowel obstruction?
- small presents with vomiting early on, before constipation
- large presents with constipation and late onset vomiting
95
What are the causes of large bowel obstruction?
- tumour
- volvulus
- diverticular disease
96
What may be the initial presenting complaint in colonic malignancy and why?
- obstruction
- distal colonic and rectal tumours obstruct earlier due to smaller lumen
97
What is the presentation of large bowel obstruction?
- symptoms of malignancy
- absence of passing flatus or stool
- abdominal pain and distention
- n+v (late symptoms - proximal lesion)
- peritonism if perforation
98
How is large bowel obstruction investigated with imaging?
- abdo X-ray: 1st line: greater than normal diameter = obstruction
- CT: high sensitivity and specificity
99
What is the management of large bowel obstruction?
- nil by mouth
- IV fluids
- NG tube with free drainage
- IV Abx if perforation, ischaemia or surgery
100
When may conservative management be appropriate in large bowel obstruction?
- stable: no peritonitis or perforation
- diverticular strictures
- slow-onset obstruction
101
When may emergency surgery be needed in large bowel obstruction?
- clinical/radiological signs of peritonitis or perforation
- evidence of ischaemic bowel
- rapid deterioration
102
What surgical option may be used in a stable large bowel obstruction patient?
- segmental resection ± primary anastamosis
103
What is a Hartmann's procedure and when is it used?
- resection with end colostomy
- emergency
- large bowel obstruction
104
What are 3 causes for a subtotal or total colectomy to be used?
- multiple synchronous tumours
- perforation
- megacolon
105
Why may a stoma formation be used as a management option in large bowel obstruction?
anastamosis is unsafe or deferred
106
What are the 2 indications for an endoscopic/colonic stent to be inserted in large bowel obstruction?
- palliative relief in patients with inoperable/metastatic colorectal cancer
- bridge to surgery: allowing decompression and optimisation prior to elective resection in high risk patients
107
What is the pathophysiology behind coeliac disease?
- T-cell mediated: auto-antibodies created in response to gluten exposure, targeting epithelial cells
- anti-tissue transglutaminase and anti-endomysial (IgA)
- affects small bowel, particularly jejunum, causing villus atrophy and malabsorption
108
Which two genes is coeliac disease associated with?
- HLA-DQ2
- HLA-DQ8
109
How does coeliac disease present?
- fatigue
- diarrhoea
- weight loss
- abdo pain/cramping/distention
- anaemia secondary to iron, B12, folate deficiency
110
What neuro symptoms are associated with coeliac disease?
- peripheral neuropathy
- cerebellar ataxia
- epilepsy
111
Describe the serology for investigating coeliac disease
- 1st line: anti-TTG (IgA) antibodies and total IgA
- IgA deficiency = possible false negative result
- looking for raised anti-TTG or anti-endomysial
112
What antibodies should be tested for in coeliac if there is an IgA deficiency?
- IgG EMA, IgG DGP or IgG TTG
113
Why is endoscopy done in coeliac disease and what is seen?
- confirm diagnosis
- crypt hypertrophy and villous atrophy
- increase in intraepithelial lymphocytes
- lymphocyte infiltration of lamina propria
114
What is the management of coeliac disease?
- lifelong gluten free diet
- pneumococcal vaccines every 5 years due to potential functional hyposplenism
115
Which conditions is coeliac disease associated with?
- T1DM
- thyroid disease
- autoimmune hepatitis
- primary biliary cirrhosis, primary sclerosing cholangitis
- dermatitis herpetiform
- IBS
116
What are complications of coeliac disease?
- anaemia (folate < B12)
- hyposplenism
- osteoporosis/malacia
- lacyose intolerance
- subfertility
117
What is volvulus?
- torsion of the colon around its mesenteric axis
- causes compromised blood flow and closed loop obstruction
118
What is sigmoid volvulus?
- large bowel obstruction
- sigmoid colon twists on sigmoid mesocolon
119
What are features of volvulus?
- constipation
- abdo pain and bloating
- nausea and vomiting
120
What are risk factors for sigmoid volvulus?
- older
- chronic constipation
- psychiatric conditions
- neuro conditions
- Chagas disease
121
What are risk factors for caecal volvulus?
- pregnancy
- adhesions
- any age
122
How is volvulus investigated and what is seen in caecal volvulus?
- abdominal X-ray
- caecal: SBO
123
What is seen on X-ray in sigmoid volvulus?
- large bowel obstruction
- dilated colon loop
- air-fluid levels
- coffee bean sign
124
How is sigmoid volvulus decompressed?
- rigid sigmoidoscopy
- rectal tube insertion
125
How is caecal volvulus managed if the bowel is viable?
- emergency laparotomy/laparoscopy
- right hemicolectomy
- prevents recurrence
- follow with primary ileocolic anastamosis
126
How is caecal volvulus managed if the bowel is non-viable?
- ischaemic/perforated
- right hemicolectomy + stoma
127
What are the symptoms of thrombosed haemorrhoids?
- significant pain
- tender lump
128
What is seen on examination of thrombosed haemorrhoids?
- purplish, oedeomatous, tender subcutaneous perianal mass
129
How are thrombosed haemorrhoids managed?
- within 72h: refer for excision
- otherwise: stool softeners, ice packs, analgesia
- symptoms settle within 10d
130
Describe the location, appearance and output of an ileostomy
- right iliac fossa
- spouted
- liquid
131
Describe the location, appearance and output of an colostomy
- more likely on L side
- flushed
- solid
132
What are the most common type of pancreatic tumour and where on the pancreas do they present?
- adenocarcinoma
- head of pancreas
133
What are the risk factors for pancreatic cancer?
- age
- smoking
- diabetes
- chronic pancreatitis
- multiple endocrine neoplasia
- BRCA2
- colorectal carcinoma (lynch syndrome)
134
What are liver features may pancreatic cancer present with?
- painless jaundice
- pale stools
- dark urine
- pruritus
- cholestatic LFTs
135
Describe the characteristic of epigastric pain in pancreatitis?
- pain radiating to the back
- worse when lying flat or after eating
136
What is the order of frequency for abdominal masses in pancreatic cancer?
- hepatomegaly (mets)
- gallbladder
- epigastric (1º tumour)
137
What is Courvoisier's Law?
- in the presence of painless obstructive jaundice, palpable gallbladder is unlikely gallstones
138
What systemic effects may occur in pancreatic cancer?
- loss of exocrine function (steatorrhoea)
- loss of endocrine function (diabetes mellitus)
- migratory thrombophlebitis (Trousseau's syndrome)
139
How is pancreatic cancer investigated and what is seen?
- USS
- high-res CT
- double duct sign: dilation of both the CBD and pancreatic ducts
140
How is pancreatic cancer managed surgically and palliatively?
- Whipple's (pancreaticduodenectomy) if resectable and in the head
- adjuvant chemo
- ERCP w/ stenting if palliative
141
What are side effects of Whipple's?
- dumping syndrome
- peptic ulcer disease
142
What are the two most common types of oesophageal cancer?
- adenocarcinoma
- squamous cell carcinoma
143
Where are the two types of oesophageal cancer tumours found?
- adenocarcinoma: lower 1/3 near gastroesophageal junction
- squamous: upper 2/3
144
What are risk factors for oesophageal adenocarcinoma?
- GORD
- Barrett's oesophagus
- smoking
- obesity
145
What are risk factors for oesophageal squamous cell carcinoma?
- smoking
- alcohol
- achalasia
146
What are features of oesophageal cancer?
- dysphagia
- anorexia and weight loss
- vomiting
- odynophagia
- hoarseness
- melaena
147
Why may advanced oesophageal cancer present with hoarseness?
- tumour in upper 1/3 pressing on recurrent laryngeal nerve
148
How is oesophageal cancer diagnosed?
- upper GI endoscopy with biopsy
- endoscopic USS for staging
- CT CAP
- PET-CT
149
How is oesophageal cancer treated?
- surgical resection: Ivor Lewis oesophagectomy
- adjuvant chemotherapy
150
What are the 3 definitions of malnutrition (BMI, % and BMI + %)?
1. BMI <18.5
2. unintentional weight loss >10% in the last 3-6 months
3. BMI <20 and unintentional weight loss >5% in last 3-6mo
151
What scoring system screens for malnutrition and what does it comprise?
- MUST
- accounts for BMI, recent weight change, acute disease
- categorises risk
152
How is malnutrition managed?
- dietician
- food-first before supplements
- oral supplements between meals
153
What is irritable bowel syndrome?
- functional bowel disorder
- due to disorders of gut motility or brain-gut axis
154
What are the symptoms of IBS?
- fluctuating bowel habit: alternating constipation and diarrhoea
- abdominal pain relieved by defecation
- bloating
- chronic and exacerbated by stress
155
What are the criteria for a positive diagnosis of IBS?
- abdo pain relieved by defecation/altered bowel frequency or stool form plus TWO:
- altered stool passage (straining, urgency, incomplete evac)
- abdo bloating, distention, tension, hardness
- symptoms worsened by eating
- passage of mucus
156
What are other symptoms that may support a diagnosis of IBS?
- lethargy
- nausea
- backache
- bladder symptoms
157
What red flag features should be enquired about in IBS history?
- rectal bleeding
- unexplained/unintentional weight loss
- FHx of bowel or ovarian cancer
- onset after 60 years
158
What bloods are done to investigate for IBS?
- FBC
- ESR/CRP
- coeliac screen (anti-TTG)
159
What is the 1st line management of IBS according to symptom (based on predominant symptom)?
- pain, cramping, bloating: antispasmodic agents e.g. mebeverine
- constipation: laxative (avoid lactulose)
- diarrhoea: loperamide
160
What is general dietary advice for IBS?
- regular meals, avoid missing meals
- >8 cups fluid per day + exercise
- inc soluble fibre, dec insoluble
- limit caffeine, alcohol, fizzy drinks, fatty foods
161
What psychological options could be considered for IBS and after what timeframe of treatment?
- CBT, hypnotherapy, psychological therapy
- if symptoms persist >12 months despite other measures
162
What is the second line constipation medication in IBS used after 12 months?
- linaclotide
- if other laxative classes and doses haven't worked
163
What is ileus and what is it a complication of?
- reduced bowel peristalsis > pseudo-obstruction
- complication of bowel surgery
- especially if extensive handling
164
What are the features of ileus?
- bloating
- abdo pain: dull, diffuse, crampy
- n+v
- can't pass flatus
- absent/reduced bowel sounds
165
How does pain in postoperative ileus differ from a mechanical obstruction?
- not colicky pain which would indicate mechanical obstruction
166
What is the management of ileus?
- NBM
- NG tube if vomiting
- IV fluids
- TPN if severe
167
What is a hiatus hernia?
- herniation of the stomach above the diaphragm
168
What are the two types of hiatus hernia?
- sliding: gastroesophageal junction moves above diaphragm (MC)
- rolling: junction remains below diaphragm but another part herniates
169
What are risk factors for hiatus hernia?
- obesity
- increased intraabdominal pressure
170
What is the presentation of hiatus hernia?
- heartburn
- dysphagia
- regurgitation
- chest pain
171
How is hiatus hernia investigated?
- barium swallow
- some may have endoscopy and found incidentally
172
What is the management of hiatus hernia (conservative, medical, surgical)?
- conservative: weight loss
- medical: PPI
- surgical: if symptoms persist: hernia repair
173
What is acute cholecystitis?
- inflammation of the gallbladder
174
What is the pathophysiology of acute cholecystitis?
- develops secondary to gallstones in most pts
- acute calculous cholecystitis
175
What is the presentation of acute cholecystitis?
- RUQ pain
- (may radiate to R shoulder)
- fever and systemic illness
176
What is Murphy's sign?
- acute cholecystitis
- inspiratory arrest on palpation of RUQ
177
What are LFTs in acute cholecystitis?
- normal
- deranged: indicates Mirizzi syndrome (gallstone impacted in cystic duct causing CBD compression)
178
How is acute cholecystitis investigated?
- 1st line: USS
- if unclear: cholescintigraphy
179
How is acute cholecystitis treated?
- IV Abx
- early lap chole within 1 week of diagnosis
- same for pregnant women
180
What are risk factors for gallstones? (4Fs)
- fat
- female: 2x more common in women due to oestrogen
- fertile: pregnancy is RF
- forty
181
What are other risk factors for gallstones? (other conditions)
- diabetes
- Crohn's
- rapid weight loss
- drugs: cocp
182
What is the pathophysiology of gallstones?
- occur due to increased cholesterol
- decreased bile salts
- biliary stasis
- pain due to gallbladder contraction against stone
183
What is the presentation of gallstones?
- severe, colicky, epigastric or RUQ pain
- may radiate to R shoulder
- triggered by meals
- n+v
184
What are LFT results in biliary colic?
- normal LFTs and inflammatory markers
- no fever
185
How are gallstones investigated?
USS
186
What is the management of gallstones?
- elective lap chole
187
What are early complications of a lap chole?
- bleeding
- bile leak
- infection
- injury to ducts
188
What is the presentation of bile leak?
- pain
- fever
- bilious drainage
189
What are causes of acute liver failure?
- paracetamol overdose
- alcohol
- viral hepatitis
- acute fatty liver of pregnancy
190
What are features of acute liver failure?
- jaundice
- coagulopathy (raised PT time)
- hypoalbuminaemia
- hepatic encephalopathy
- renal failure common
191
What bloods are best used to assess liver function other than LFTs?
- prothrombin time
- albumin level
192
Where are the mucosal vascular cushions found in the anal canal?
- left lateral (3)
- right posterior (7)
- right anterior (11)
193
What are the features of haemorrhoids?
- painless rectal bleeding
- pruritus
- pain (if thrombosed)
- soiling if severe
194
Describe the difference in location and pain between internal and external haemorrhoids
- internal: originate below dentate line, prone to thrombosis, may cause pain
- external: originate above dentate line, painless
195
Describe the 4 grades of haemorrhoids
I: do not prolapse
II: prolapse on defecation, spontaneously reduce
III: manually reduced
IV: irreducible
196
What is the conservative/at home medical management of haemorrhoids?
- conservative: inc fibre and fluid
- topical local anaesthetics and steroids
197
What are outpatient procedures that can be done for haemorrhoids?
- rubber band ligation
- injection sclerotherapy
198
What is an anal fissure and how to differ acute and chronic?
- longitudinal or elliptical tear of the squamous lining of the distal anal canal
- acute: <6 weeks, chronic >6 weeks
199
What are risk factors for anal fissure?
- constipation
- IBD
- STIs
200
What is the presentation of anal fissure and where do they most commonly occur?
- painful, bright red, rectal bleeding
- posterior midline is MC
- if alternative location, consider other causes
201
What is the management of an acute anal fissure?
- stool softening: diet and bulk forming laxatives
- petroleum jelly before defecation
- topical anaesthetics
- analgesia
202
How are chronic (>6 weeks) anal fissures managed?
- same as acute
- 1st line: topical GTN
- 2nd line: topical diltiazem
- if ineffective after 8wks: consider
lateral internal sphincterotomy
- if sphincterotomy fails/CI: botox injection
203
What are pancreatic causes of malabsorption?
- chronic pancreatitis
- pancreatic cancer
- cystic fibrosis
204
What are small bowel causes of malabsorption?
- coeliac disease
- Crohn's disease
- small bowel resection
205
What are hepatobiliary causes of malabsorption?
- primary biliary cirrhosis
- ileal resection
- post cholecystectomy
206
What is the presentation of malabsorption?
- diarrhoea
- steatorrhoea
- weight loss
- anaemia, osteoporosis, peripheral neuropathy
207
What are the causes of bile acid malabsorption?
- 1º: excess production of bile acid
- 2º: cholecystectomy, coeliac, small intestine bacterial overgrowth
208
How is bile acid malabsorption investigated?
- SeHCAT
- nuclear medicine test using selenium molecule
- scans done 7d apart to assess retention of radioisotope
209
How is bile acid malabsorption managed?
- cholestyramine
210
Where is inflammation located in ulcerative colitis?
- starts in rectum
- never spreads beyond ileocaecal valve
- continuous
211
In what ages is the peak incidence of ulcerative colitis?
- 15-25
- 55-65
212
What are the typical characteristics of Crohn's (NESTS)
- No blood or mucus
- Entire GI tract (mainly ileum)
- Skip lesions: unaffected areas between active disease
- Terminal ileum (and proximal colon) most affected with transmural inflammation
- Smoking is a risk factor
213
What are the characteristics of ulcerative colitis (CLOSE)?
- continuous inflammation
- limited to colon and rectum
- only superficial mucosa affected
- smoking is protective
- excreted blood and mucus
214
When and how does Crohn's present?
- presents in late adolescence/early adulthood
- diarrhoea (bloody if colitis)
- abdominal pain
- weight loss/lethargy (systemic)
215
What may be seen on bloods in Crohn's?
- raised inflammatory markers
- inc faecal calprotectin
- anaemia
- low vit B12 and D
216
What are some specific features of the presentation of ulcerative colitis?
- blood and mucus with gradual onset of diarrhoea
- bowel frequency related to severity of disease
- crampy abdominal discomfort
- tenesmus
- LLQ abdo pain
217
What extra intestinal features related to disease activity are seen in both Crohn's and UC?
- arthritis (asymmetric)
- erythema nodosum
- episcleritis
- osteoporosis
218
What extra intestinal features UNrelated to disease activity are seen in both Crohn's and UC?
- symmetrical arthritis
- uveitis
- clubbing
- primary sclerosing cholangitis
219
How is ulcerative colitis investigated and what is the alternative in severe disease and why?
- colonoscopy + biopsy
- if severe: flex sigmoidoscopy due to risk of perf
220
What is seen on endoscopy in ulcerative colitis?
-red, raw mucosa, bleeds easily
- inflammation not beyond submucosa
- widespread ulceration but adjacent mucosa preserved giving pseudopolyps (polyp appearance)
- crypt abscesses
- depletion of goblet cells and mucin from epithelium
221
What is seen on barium enema in ulcerative colitis?
- loss of haustrations
- superficial ulceration (pseudopolyps)
- short, narrow 'drainpipe' colon
222
What factors may be linked to ulcerative colitis flares?
- stress
- meds: NSAIDs and Abx
- smoking cessation
223
Describe a mild ulcerative colitis flare?
- <4 stools daily ± blood
- no systemic disturbance
- normal ESR and CRP
224
Describe a moderate ulcerative colitis flare
- 4-6 stools daily
- minimal systemic disturbance
225
Describe a severe ulcerative colitis flare
- >6 stools daily + blood
- systemic: fever, tachycardia, abdo tenderness/distention, anaemia, hypoalbuminaemia
226
What are the 3 surgical options in ulcerative colitis?
- subtotal colectomy
- restorative proctocolectomy
- complete panproctocolectomy
227
What is a subtotal colectomy?
- UC management
- removal of part of colon
- temporary loop ileostomy to protect anastamosis (can be reversed)
228
What is a restorative proctocolectomy?
- UC management
- total colectomy
- ileal pouch joined to anal canal
- temporary loop ileostomy which is reversed
229
What is a complete panproctocolectomy?
- UC management
- removal of entire colon and rectum
- permanent ileostomy, no anastamosis
230
What is given in ulcerative colitis to maintain remission following severe relapse or ≥2 exacerbations in the past year?
- oral azathioprine
- oral mercaptopurine
231
How is remission induced in mild-to-moderate UC, where proctitis is the main concern?
- topical: rectal mesalazine
- if remission not achieved within 4 weeks: add oral aminosalicylate
- if still not achieved: add topical or oral corticosteroid (prednisolone)
232
How is remission induced in mild-to-moderate UC, where proctosigmoiditis/left-sided UC is the main concern?
- rectal mesalazine
- after 4 wks: add a high-dose oral aminosalicylate/ switch to high-dose oral aminosalicylate and topical corticosteroid
- if unachieved: oral both
233
How is remission induced in mild-moderate extensive UC?
- rectal mesalazine
- high dose oral mesalazine
- if not within 4wks: stop topical and + high dose oral mesalazine and oral corticosteroid
234
How is severe colitis treated, what should be given if contraindicated and what should be done if no improvement after 72h?
- in hospital
- IV steroids
- IV ciclosporin if steroids CI
- after 72h: add IV ciclosporin/consider surgery
235
How is remission maintained after a mild-moderate UC flare (proctitis and extensive)?
- rectal mesalazine (daily or intermittent)
- oral mesalazine plus rectal mesalazine (daily or intermittent)
- if extensive: low maintenance dose of oral mesalazine
236
Which drug that is used in Crohn's should not be used in UC?
- methotrexate
237
How is remission induced in Crohn's disease if first presentation/1 flare in 12 mo
What is used if contraindicated/right sided/ileal disease?
- prednisolone, methylprednisolone or IV hydrocortisone
- R side: budesonide
238
What are the second line drugs used in Crohn's?
- mesalazine
- azathioprine
239
What drugs are prescribed in add-on treatment in Crohn's if there are ≥2 inflammatory exacerbations in 12 mo?
- azathioprine
- mercaptopurine
- methotrexate if above 2 not tolerated
240
What drugs should be used to maintain remission in patients with Crohn's following surgery?
- azathioprine and metronidazole
241
What drugs are used to maintain remission in Crohn's?
- azathioprine
- mercaptopurine
242
What surgery may be done in patients with Crohn's?
- ileocaecal resection
- stricuroplasty
243
What are complications of Crohn's?
- small bowel cancer
- colorectal cancer
- osteoporosis
244
What is a perianal fistula?
- inflammatory connection between anal canal and perianal skin
245
How are perianal fistulae treated?
- oral metronidazole
- infliximab
- draining seton (surgical thread)
246
What is seen on colonoscopy in Crohn's?
- deep ulcers
- skip lesions
247
What is seen on histology in Crohn's?
- inflammation from mucosa to serosa
- goblet cells
- granulomas
248
What is seen on small bowel enema in Crohn's?
- strictures
- proximal bowel dilation
- rose thorn ulcers
- fistulae
249
What is a potential complication of multiple surgeries in Crohn's and how may it be managed?
- short bowel syndrome
- localised stricturoplasty to preserve intestinal length
250
What type of bacteria is C. difficile?
- anaerobic gram positive rod
251
Which antibiotics cause C. difficile
- clindamycin
- cefotaxime
- ceftriaxone
252
What is the pathophysiology of C. diff?
- spore forming, toxin producing bacillus
- transmitted via faecal-oral route
- releases exotoxins A and B which act on intestinal epithelial cells, causing colitis
253
What are the features of C. diff infection?
- diarrhoea
- abdo pain
- raised WCC
- can develop severe toxic megacolon
254
What are the causes of ascites with a SAAG >11g/L?
- indicates portal htn
- liver: cirrhosis, acute liver failure, mets,
- cardiac: RH failure, constrictive pericarditis
- portal vein thrombosis
255
What are the causes of ascites with a SAAG <11g/L?
- Low albumin: nephrotic syndrome, severe malnutrition
- malignancy
- Infections
- pancreatitis
- bowel obstruction
256
What is the management of ascites?
- reduce dietary sodium
- fluid restriction if low sodium
- aldosterone antagonists e.g. spironolactone
- drainage: therapeutic paracentesis
257
What medication is given for spontaneous bacterial peritonitis?
- prophylactic oral ciprofloxacin or norfloxacin
- ascitic protein of ≥15 g/l
258
What is the presentation of appendicitis?
- anorexia
- mild pyrexia
- guarding
- rebound and percussion tenderness
259
Describe the pain in appendicitis
- central abdo pain > R iliac fossa
- worse on coughing and going over speed bumps
- tenderness at McBurney's point on palpation
260
What is seen on abdo exam of acute appendicitis?
- rebound and percussion tenderness
- guarding
- rigidity
- R sided tenderness on DRE
261
What is Rovsing's sign?
- palpation of LIF causes pain in RIF
262
How is appendicitis diagnosed? (blood results too)
- clinical presentation
- raised inflammatory markers
- neutrophil predominant leucocytosis
- contrast CT/USS for females
- potential diagnostic laparoscopy
263
What investigations may be done in appendicitis in females?
- urinalysis
- ultrasound
- excludes pregnancy and pelvic pathology
264
What are the key differential diagnoses of appendicitis?
- ovarian cysts
- Meckel's diverticulum
- ectopic pregnancy (hCG to exclude)
265
How is appendicitis managed?
- appendicectomy
- prophylatic IV Abx
- laparoscopic surgery is ideal over open
266
What is ischaemic colitis?
- acute transient compromise in blood flow
267
Where is ischaemic colitis likely to occur?
- splenic flexure
268
What is seen on X-ray in ischaemic colitis?
thumbprinting
269
What are causes of hyposplenism?
- splenectomy
- sickle-cell
- coeliac
- Graves
- SLE
270
What are the features on blood film of hyposplenism?
- Howell-Jolly bodies
- siderocytes
271
What is constipation?
- infrequent stools (<3x weekly)
- difficult stool passage
- incomplete defecation
272
What is the first line laxative for constipation?
- bulk-forming
- ispaghula hulk
273
What is the second line laxative for constipation?
- osmotic laxative e.g. macrogol
274
What are the features of an inguinal hernia?
- groin lump
- superior and medial to pubic tubercle
- disappears on pressure/when pt lies down
- discomfort worse with activity
275
What is the surgical management of inguinal hernia? Which approaches are used for unilateral vs bilateral?
- treat pts even if asymptomatic
- unilateral: open approach
- bilateral/recurrent: laparoscopic
276
Immediate complications of inguinal hernia repair (Intra-op to 24 hours):
- bleeding / ____ (particularly in the scrotum or groin)
- injury to ____, iliohypogastric, or genitofemoral nerves
- the ____ nerve is the most commonly injured and may lead to numbness or tingling over the ____ thigh, base of penis, or anterior scrotum/labia
- injury to vas deferens: May cause ____ (especially in younger males)
- bowel injury or bladder perforation (rare): Suspect if haematuria or peritonitis post-op
Immediate complications of inguinal hernia repair (Intra-op to 24 hours): Immediate (Intra-op to 24 hours)
- bleeding / **Haematoma** – particularly in the scrotum or groin
- injury to **ilioinguinal**, iliohypogastric, or genitofemoral nerves
- the **ilioinguinal** nerve is the most commonly injured and may lead to numbness or tingling over the **superomedial** thigh, base of penis, or anterior scrotum/labia
-injury to vas deferens: May cause **infertility** (especially in younger males)
- bowel injury or bladder perforation (rare): Suspect if haematuria or peritonitis post-op
277
Early complications of inguinal hernia repair (1–30 days):
- wound infection: Redness, swelling, discharge; may require antibiotics
- ____ / Haematoma: Groin or scrotal swelling; usually self-limiting
- urinary retention: More common in older men or after spinal anaesthesia
- ____ ischaemia or atrophy: Due to compromised gonadal vessels during dissection
Early complications of inguinal hernia repair (1–30 days):
- wound infection: Redness, swelling, discharge; may require antibiotics
- **seroma** / Haematoma: Groin or scrotal swelling; usually self-limiting
- urinary retention: More common in older men or after spinal anaesthesia
- **testicular** ischaemia or atrophy: Due to compromised gonadal vessels during dissection
278
Late complications of inguinal hernia repair (weeks to years):
- chronic ____ pain (inguinodynia): Often ____; due to nerve entrapment or mesh
- recurrence of hernia: More common with tension repair or poor tissue quality
- mesh-related complications: Mesh infection, ____, erosion into viscera (e.g. bladder)
Late complications of inguinal hernia repair (weeks to years):
- chronic **groin** pain (inguinodynia): Often **neuropathic**; due to nerve entrapment or mesh
- recurrence of hernia: More common with tension repair or poor tissue quality
-mesh-related complications: Mesh infection, **migration**, erosion into viscera (e.g. bladder)
279
What are risk factors for abdominal wall hernias?
- obesity
- ascites
- age
- surgical wounds
280
What are features of abdominal wall hernias?
- palpable lump
- cough impulse
- pain
- obstruction
- strangulation
281
What is the presentation of epigastric hernia?
- lump in midline between umbilicus and xiphisternum
282
What is an obturator hernia and how does it present?
- hernia through obturator foramen
- presents with bowel obstruction
283
What are the features of femoral hernia?
- mildly painful lump in groin
- non-reducible
- absent cough impulse
284
What is the epidemiology of femoral hernia?
- more common in females
- more common in multiparous women
285
What are the complications of femoral hernia?
- incarceration > strangulation
- bowel obstruction
- bowel ischaemia
286
What is the management of femoral hernia?
- surgical repair
- laparoscopic ideally
287
What is an incarcerated hernia?
irreducible hernia
288
What are the 2 most common locations of colorectal cancers?
- rectum
- sigmoid
289
What are the presenting features of colorectal cancer?
- change in bowel habit
- rectal bleeding
- abdo pain
- unexplained weight loss
- anaemia
- bowel obstruction
290
How often is FIT screening done and to what age group is it offered?
- every 2 years
- between ages 50 and 74
291
What is HNPCC in relation to colorectal cancer? Give the inheritance
- Lynch syndrome
- autosomal dominant
- most common form of inherited colon cancer
292
What is carcinoid syndrome?
- occurs when liver mets release serotonin
293
What are the features of carcinoid syndrome?
- flushing
- diarrhoea
- bronchospasm
- hypotension
- RH valvular stenosis
294
How is carcinoid syndrome investigated?
- urinary 5-HIAA
- plasma chromogranin A y
295
What is the management of carcinoid syndrome?
- octreotide (somatostatin analogue)
- cyproheptadine (for diarrhoea)
296
What is acute mesenteric ischaemia, which artery is affected and which cardiac condition is usually present in the history?
- caused by embolism occluding an artery supplying small bowel
- superior mesenteric artery
- Hx of AF
297
What is seen on VBG in acute mesenteric ischaemia?
- metabolic acidosis with raised lactate
298
How is acute mesenteric ischaemia diagnosed?
- high res CT angiography without oral contrast
299
How is acute mesenteric ischaemia managed and what indications call for increased urgency?
- immediate laparotomy
- peritonitis or sepsis
300
What is the pathophysiology of chronic mesenteric ischaemia?
- atherosclerotic narrowing of mesenteric arteries
301
What are the features of chronic mesenteric ischaemia?
- postprandial abdominal pain (crampy, 30–60 mins after eating)
- weight loss (due to food avoidance)
- nausea, bloating, diarrhoea or altered bowel habits
- abdominal bruit might be heard
302
What is the first line investigation for chronic mesenteric ischaemia? What is seen on duplex USS?
- CT angiography is the first-line diagnostic test
- duplex ultrasound may show reduced flow in mesenteric vessels
303
How is chronic mesenteric ischaemia managed?
- smoking cessation
- optimise CV risk factors
- revascularisation (stenting/bypass)
MLA
flashcards
Decks in class (28)
# Cards
-
Renal148
-
Respiratory161
-
CV264
-
Derm109
-
Endocrinology271
-
Oncology72
-
Rheumatology226
-
3a Neuro228
-
3a Obstetrics247
-
GI303
-
Ophthalmology250
-
ENT102
-
Gynaecology286
-
Paeds resp117
-
Paeds GI130
-
Sexual Health105
-
Paeds endo26
-
Paeds cardio59
-
Haematology158
-
Ortho90
-
Anaesthesia + surgery4
-
Paeds neuro52
-
Paeds derm41
-
Paeds infectious68
-
Psychiatry269
-
Paeds MSK69
-
Paeds renal5
-
Paeds Genetics38
