0
Q
What is the pathogenesis of GORD ?
A
- Weakened oesophageal sphincter, allowing stomach acid into oesophagus
- stomach over producing acid, overflow more likely
1
Q
How common is GORD?
A
80% of population
2
Q
What are the lifestyle risk factors for GORD ?
A
- obesity
- pregnancy
- diet: fat, choc, caffeine, alcohol, large meals
- smoking
3
Q
What drugs can increase risk of GORD ?
A
Anti muscarinics
Calcium channel blockers
Nitrates
4
Q
When should GORD be investigated further/red flags
A
- Dysphagia
- > 55yrs
- > 4 weeks persistent symptoms despite treatment
5
Q
What is first line drug treatment for GORD ?
A
PPI - omeprazole 20 mg daily
6
Q
Second line drug treatment for GORD
A
H2 receptor antagonist e.g. Ranitidine
7
Q
First line treatment for H Pylori eradication ?
A
7 day, twice daily course:
PPI and
Amoxicillin and
Clarithromycin OR metronidazole (dependant on previous exposure)
If allergic to penicillin give
PPI, clarithromycin and metronidazole
8
Q
Name 5 complications of GORD
A
BOROH:
- Barrett oesophagus
- Oesophageal carcinoma
- Reflux oesophagitis
- Oesophageal ulceration
- Hernia
9
Q
What is the pathological change in barrett’s oesophagus ?
A
Epithelium metaplasia: squamous > columnar
10
Q
What percentage of the population are affected by peptic ulcers ?
A
10-15%
11
Q
Which are more common, gastric or duodenal ulcers ?
A
Duodenal (2-3x more common)
12
Q
Where do duodenal ulcers most commonly form ?
A
Duodenal cap
13
Q
Where do gastric ulcers most commonly form ?
A
Lesser curvature of stomach (usually in the elderly)
14
Q
What is the pathogenesis of peptic ulcers ?
A
Breakdown of superficial epithelial cells all the way down to the muscularis mucosa (fibrous base with inflammatory cells), with no mucous protection acid breaks down stomach/duodenal wall
15
Q
What is the most common aetiology of peptic ulcers ?
A
H pylori
16
Q
How does h pylori cause peptic ulcers ?
A
h pylori colonises the mucosa layer of gastric Antrum via adhesion to gastric mucosal cells and causes gastritis by release of toxins:
- CagA product is injected into epithelial cells via a pilus; changes cell morphology, replication and apoptosis
- VacA is a pore-forming protein which increases host cell permeability, inducing apoptosis
17
Q
What are the risk factors for peptic ulcers ?
A
- H pylori
- smoking (impairs mucosal healing)
- history of reflux
- NSAIDs
- delayed gastric emptying/ increased gastric acid production
- blood group O (duodenal ulcers)
- stress (gastric ulcers)
18
Q
Stress is a risk factor for which type of peptic ulcer ?
A
Gastric
19
Q
Blood group O is a risk factor for which type of peptic ulcer ?
A
Duodenal
20
Q
What is the initial treatment for peptic ulcers?
A
Offer full dose PPI or H2RA for 4-8 weeks
- stop NSAIDS
- H Pylori eradication
21
Q
What are the ALARMS symptoms relating to peptic ulcers ?
A
A- Anorexia (early satiety) L- weight Loss A- Anaemia R- Recent onset of progressive symptoms M- Melena S- Swallowing difficulty
22
Q
When to refer a peptic ulcer for urgent endoscopy ?
A
> 55yrs
+ ALARM symptoms (bleeding, early satiety etc)
23
Q
Lifestyle changes for peptic ulcer disease
A
Raise head end of bed
Not eat <3hrs before going
Stop alcohol
24
A patient has burning epigastric pain that they can point to with a single finger. It is worse when they're hungry (2-3hrs after last meal)What is the likely diagnosis of this presentation ?
Duodenal ulcer
- worse 2-3hrs after food as this is when stomach contents release in to duodenum
* gastric ulcer worse on eating*
25
Name the non-invasive tests for H Pylori
- serological tests: detect IgG antibodies; 90% sensitive, 83% specific
- 13c-urea breath test: quick, reliable, screening test; ingest 13c-urea which is broken down by urease
- stool antigen test: immunoassay mAb for qualitative detection of H Pylori
26
What are the invasive tests for h pylori
Endoscopy:
- biopsy urease test: gastric biopsies are added to a substrate containing urea and phenol red; if h pylori present, releases ammonia, causing colour to change from yellow to red
- culture
- histology: giemsa staining sections of gastric mucosa obtained at endoscopy
27
Rare endocrinopathy resulting in recurrent peptic ulcers ?
Zollinger-Ellison syndrome: gastric secreting tumours
28
What is a Cushing ulcer ?
Gastric ulcer caused by raised intracranial pressure stimulating vagus nerve to produce more acid (vagus nerve releases acetylcholine which stimulates m3 receptors on parietal cells and activates second messenger to stimulate hydrogen potassium pump, which will increase gastric acid production)
29
Complications if peptic ulcers
Haemorrhage
Perforation of ulcer
Malignancy
Gastric outflow obstruction
30
Which type of peptic ulcer is more likely to perforate ?
Duodenal
31
What are the 2 most common causes of acute lower GI bleed ?
Diverticula disease
| Ischaemic colitis
32
Most common causes of upper GI bleed ?
```
Perforated gastric ulcers
NSAIDs
Alcohol - gastric varices
Reflux oesophagitis
Mallory-Weiss tears
```
33
What is the Glasgow-batchford score ?
Score stratifying upper GI bleeds into low and high risk based on:
- hb level
- BP
- sex
- HR
- Melena
- recent syncope
- hepatic disease history
- HF history
Zero is low risk, anything higher needs medical intervention
34
How are acute upper GI variceal bleeds treated ?
Terlipressin
| Offer prophylactic antibiotics
35
Treatment for non variceal upper GI bleeds ?
Adrenaline and thermal coagulation
36
Which is more common, Crohn's disease or ulcerative colitis ?
Ulcerative colitis
37
Who does Crohn's most often affect ?
Females
Immunocompromised
Hispanic, Asian, Jewish
38
Deep transluminal inflammation of whole GI tract is characteristic of which condition ?
Crohn's
39
Cobblestone appearance, skip lesions and granulomas are characteristic in which IBD condition ?
Crohn's
40
Is Crohn's or ulcerative colitis more likely to cause strictures and fistulas ?
Crohn's
41
Superficial inflammation confined to the mucosa over the rectum, colon, appendix and terminal ileum is characteristic of which IBD condition ?
UC
42
Goblet cells are depleted in which IBD condition ?
UC
43
Which IBD condition results in the presence of inflammatory cells in the lamina propria ?
UC
44
What is the biggest risk factor for IBD ?
Familial history of IBD
45
How does s,oping affect the risk of Crohn's and ulcerative colitis ?
Crohn's - smoking increases risk
| UC - smoking decreases risk
46
A presentation of history of diarrhoea with blood, RIF abdo pain and palpable mass with weight loss and anorexia is likely to be what ?
Chrohns disease
47
Is Crohn's or UC more likely to have anal symptoms ?
Crohn's
| E.g. Oedematous anal tags, fissures, perinatal abscess
48
When is faecal calprotectin testing recommended ?
To support differential of IBS or IBD (+ve = IBD) when specialist investigation is being considered (if cancer not suspected)
Calprotectin is a substance that is released in excess in the intestines when inflammation is there
49
Which part of the GI tract is Crohn's disease most likely to affect ?
Terminal ileum and proximal colon
50
What type of inflammation is found in Crohn's disease ?
Focal, asymmetric, transmural and sometimes granulomatous inflammation
51
Which infectious agents have been linked with Crohn's disease ?
- mycobacterium paratuberculosis
- pseudomonas spp
- listeria spp
52
What are the theories on causes of Crohn's ?
- infectious agents
- increase in TNF-alpha
- high fat diet
- genetic mutation
53
Which inflammatory bowed disease presents with skip lesions ?
Crohn's
54
What ages is Crohn's disease most likely to present ?
15-30 then again at 60-80
55
What age is UC most likely to present ?
15-25
56
What are the extraintestinal manifestations of ulcerative colitis ?
- erythema nodosum
- aphthous ulcers
- epi scleritis
- acute arthropathy affecting the large joints
57
What are the extraintestinal manifestations of Crohn's disease ?
- clubbing
- erythema nodosum
- large joint arthritis
- fatty liver
- osteomalacia
58
Which antibody can be tested for that is more common in Crohn's than UC ?
Anti-S cerevisiae antibodies (ASCA)
59
Which antibodies can be tested for that are more common in UC than Crohn's ?
Peri nuclear antineutrophil cytoplasmic antibody (p-ANCA)
60
What initial investigations should be carried out for a suspected case of IBD ?
- FBC, U&Es, LFTs, ESR, CRP
- stool culture to rule out parasites and c diff.
- faecal calprotectin (rule out IBS)
- serological markers (e.g. p-ANCA) or ASCA)
- sigmoidoscopy / colonoscopy and biopsy to differentiate between macroscopic findings
61
Differential diagnoses in IBD
- Crohn's vs UC
- Behçet's disease
- coeliac
- diverticulitis
- Ischaemic colitis
62
Which drugs can precipitate paralytic ileus and mega colon in active colitis ?
Antimotility drugs:
- codeine
- loperamide
Antispasmodics
63
Complications of IBD ?
- toxic mega colon
- haemorrhage
- stricture & fistula (UC more common)
- large bowel carcinoma
- colorectal cancer
64
What drug is used to maintain remission in IBS ?
Mesalazine (aminosalicylate)
65
Which drugs induce remission in IBD ?
Corticosteroids
66
What percentage of the population is affected by IBS ?
10-20%
67
Who is IBS most likely to occur in ?
Women
| Ages 20-30
68
What is the pathogenesis of IBS ?
No detectable organic cause
- due to biopsychosocial interactions causing dysregukation of brain-gut function
- abnormal central processing of painful stimuli
- associated with increased psychological distress and poor coping strategies
69
What are the risk factors for IBS ?
- affective disorders e.g. Anxiety, depression
- psychological stress and trauma, life events
- GI Infection
- Antibiotic therapy
- sexual, physical or verbal abuse
- female
- eating disorders
70
What conditions does IBS often coexist with ?
- chronic fatigue syndrome
- fibromyalgia
- TMJ joint dysfunction
71
What are the non-GI features of IBS ?
- gynae: dysmenorrhea, dyspareunia, premenstral tension
- urinary: frequency, urgency, nocturia, incomplete emptying
- other: back pain, headaches, bad breath, poor sleeping, fatigue
-
72
Classic presentation of IBS ?
- improvement of abdo pain in defecation
- onset of pain associated with change in frequency of stool
- onset of pain associated with a change in appearance of stools
73
What are the non pharmacological treatments for IBS
- probiotics
- eradicate dietary triggers
- high fibre diet and fibre supplements
- psychotherapy, CBT
74
What investigations should be carried out to rule out other conditions if IBS suspected ?.
- upper GI endoscopy (dyspepsia, reflux)
- duodenal biopsy (coeliac)
- giardia test
- ERCP (chronic pancreatitis)
-
75
Pharmacological treatment for IBS ?
- loperamide for diarrhoea
| - mebeverine antispasmodic for colic/bloating
76
What are the risk factors for infective gastroenteritis ?
- poor hygiene/lack of sanitation
- immunocompromised
- food hygiene/undercooked
77
By what mechanism does E. coli. Cause gastroenteritis ?
Mucosal adherence- adhere to receptors in the gut allowing entry of a subunit in to cell which activates adenylyl cyclase which increases amount of cAMP and results in intense and prolonged hyper secretion of chlorides and water while inhibiting reabsorption of sodium
- gut contains large amount of fluid leading to diarrhoea
78
Bloody diarrhoea in gastroenteritis would be suspicious if what causative organism ?
Bacterial, particularly E. coli , salmonella and shigella if from exotic location
79
What is the most common causative organism of outbreaks of gastroenteritis in the UK ?
Rotavirus, norovirus (winter)
80
What is the incubation period of viruses causing gastroenteritis ?
1 day
81
What is the incubation period for bacillary dysentery ?
Few hours to 4 days
82
What is the main risk to health in adult gastroenteritis ?
Dehydration
83
What are the signs of mild dehydration ?
Lassitude, anorexia, nausea, light headedness, postural hypotension
84
Features of moderate dehydration ?
- Apathy
- tiredness
- dizziness
- muscle cramps
- dry tongue
- sunken eyes
- reduce skin elasticity
- tachycardia
- oliguria
85
Features of severe dehydration?
- profound apathy
- weakness
- confusion
- shock
- tachycardia
- peripheral vasoconstriction
- BP systolic
86
When should a stool sample be sent off in an adult with gastroenteritis ?.
- blood/mucous in stool *
- immunocompromised *
- exotic travel
- not improved by day 7
- uncertain diagnosis
87
What blood tests should be sent for in an unwell patient with gastroenteritis ?
FBC, U&Es
88
Differential diagnoses in a patient with suspected gastroenteritis
- travellers diarrhoea
- UTI
- constipation overflow
- IBS
- Addison's disease
89
Complications of gastroenteritis
- haemolytic uraemic syndrome (HUS) (haemolytic anaemia, thrombocytopenia and AKI)
- systemic invasion e.g. Salmonella
- toxic mega colon
- Guillain-Barré syndrome - CMV, campylobacter jejuni
- IBS
90
What is exudative diarrhoea ?
Presence of pus or blood in stools
91
What is the mechanism of secretory diarrhoea ?
- increase in active secretion or inhibition of absorption
- no structural damage
- e.g. Cholera toxin: stimulates secretion of anions such as chloride, which then stimulates secretion of sodium in to lumen (to balance charge), water follows sodium --> watery diarrhoea
92
Which type of diarrhoea does not stop after oral intake is stopped ?
Secretory
93
What is osmotic diarrhoea ?
- Too much water is drawn in to lumen due to excessive molecules in lumen upsetting balance e.g. Malabsorption or excessive intake of sugar
- stops when intake stopped
94
What type of diarrhoea occurs in coeliac disease ?
Osmotic
95
What is the pathogenesis of inflammatory diarrhoea ?
- Damage to mucosal lining/brush border results in passive loss of protein rich fluid and deceased ability to reabsorb lost fluid
- may have features of all types of diarrhoea
96
Examples of causes of inflammatory diarrhoea ?
- IBD
| - infections
97
Give an example of an opioid used as an antidiarrhoeal ?
Loperamide, only acts on receptors in large bowel so does not have CNS effects
98
How do anticholinergics reduce diarrhoea ?
Reduce intestinal movements, also effective against cramp
99
When do you manage gastroenteritis in hospital ?.
Severely dehydrated
100
What antibiotic can treat gastroenteritis caused by salmonella, cholera and shigella ?
Ciprofloxacin
101
Around what age is acute pancreatitis most likely to present ?
60
102
How might gallstones cause acute pancreatitis ?
- block bile duct causing back pressure in to main pancreatic duct
103
What drugs may cause acute pancreatitis ?
- thiazides
- valproate
- corticosteroids
104
What viruses have been linked with acute pancreatitis ?.
- coxsackie B
- hepatitis
- mumps
105
Symptoms of acute pancreatitis ?
- severe upper abdo pain
- sudden onset vomiting
- pain focused in LUQ of epigastrium and penetrates to back
- pain decreases steadily over 72 hours
106
Why might patients with acute pancreatitis present with jaundice ?
Gallstone in common bile duct
107
What is cullen's sign ?
Superficial oedema and bruising around umbilicus - can predict acute pancreatitis
(May also be seen in ruptured ectopic pregnancy, abdo trauma, aortic rupture)
108
What is grey turners sign ?
Bruising of flanks - sign of retro peritoneal haemorrhage (pancreatic necrosis) can predict severe attack of acute pancreatitis
109
What investigations should be done for acute pancreatitis ?
- Bloods: serum amylase, lipase, CRP, FBC, U&Es, glucose, calcium
- abdo x Ray: exclude perforation/obstruction and show any calcification
- CXR: may show elevated hemi diaphragm, infiltrates and acute respiratory distress syndrome
- ultrasound: confirm gallstones
110
What would raised bilirubin and/or serum aminotransferases suggest for the cause of acute pancreatitis ?
Gallstones
111
What are the causes of raised amylase ?
- acute pancreatitis
- renal failure
- ectopic pregnancy
- DKA
- perforated duodenal ulcer
- mesenteric infarct/Ischaemia
112
What conditions cause similar pain to acute pancreatitis ?
- small bowel perforation/obstruction
- ruptured/dissecting aorta
- atypical MI
113
Which diseases are associated with acute pancreatitis ?
- gallstones
- alcoholism
- hyperlipidaemia
- hypothermia
114
Why is morphine not used to control pain in acute pancreatitis ?
Linked to spasm of sphincter if Oddi (sphincter at bottom of biliary tree controlling flow of pancreatic juices and bile)
115
What pain relief is used in mild cases of acute pancreatitis ?
- pethidine OR buprenorphine +/- IV benzodiazepines
116
When would surgery be required in acute pancreatitis ?
If infection and necrosis are present (debridement)
117
Complications of acute pancreatitis ?
- pancreatic necrosis
- infected necrosis
- acute fluid collections (don't require surgery)
- pancreatic abscess
- acute pseudo-cyst
- pancreatic Ascites
- acute cholecystitis
118
What shod be done for the prevention of acute pancreatitis ?
- avoid alcohol
- treat gallstones
- plasmapheresis may reduce incidence Those with severe hypertriglyceridaemia
119
Who is chronic pancreatitis most likely to affect ?
Males over 40, alcoholics
120
Pathogenesis of chronic pancreatitis ?
- obstruction or reduction of bicarbonate excretion
- activates pancreatic enzymes
- leads to pancreatic tissue necrosis and eventual fibrosis
- alcohol causes proteins to precipitate in the ductal structures of the Pancreas
- leads to local pancreatic dilatation and fibrosis
121
How is large duct pancreatitis characterised ?
- Dilatation and dysfunction of the large ducts - easily seen on imaging
- diffuse pancreatic calcification
- steatorrhoea common
- replacement of pancreatic enzymes does not relieve pain, surgery required
122
Which subtype of chronic pancreatitis occurs more in men than women ?
Large duct pancreatitis
123
Characteristics of small duct pancreatitis ?
- occurs more in women
- not associated with calcifications
- imaging usually normal
- steatorrhoea rare
- patients respond to pancreatic enzyme replacement
124
Predisposing factors for chronic pancreatitis ?.
- smoking
- alcohol abuse
- genetic - GGT1, CFTR, SPINK1 genes
125
Causes of chronic pancreatitis ?
- biliary tract disease
- iatrogenic
- metabolic disorders e.g. Hypertriglyceridaemia, hypercalcaemia
- trauma
- congenital e.g. CF
- drugs e.g. Sulphonamides, loop diuretics
-
126
Presentation of chronic pancreatitis ?
- abdo pain: epigastric -> back
- nausea and vomiting
- anorexia
- exocrine dysfunction e.g. Malabsorption and weight loss, diarrhoea, steatorrhoea, protein deficiency
- endocrine dysfunction e.g. DM
Examination = unremarkable, tender abdo
127
What bloods should be investigated Chronic pancreatitis ?
FBC, U&Es, LFTs, creatinine, calcium, Amylase, (usually normal), glucose, hba1c
128
Complications of chronic pancreatitis ?
- cobalamin deficiency
- DM
- percardial/pleural effusion
- pseudo cyst
- GI bleed (pseudo cyst invading duodenum)
- pancreatic carcinoma
129
What are the 2 most common presentations of gallstones ?
- acute cholecystitis
| - biliary colic
130
What are the types of gallstones and what are their causes ?(4)
- pigment stones: small, friable, irregular - haemolysis (radiolucent)
- cholesterol stones: large, solitary, - age, obesity (radiolucent)
- mixed: calcium salts, pigment, cholesterol (radiopaque)
131
Risk factors for gallstones
- increasing age
- obesity
- female
- positive family history
- sudden weight loss e.g. After obesity surgery
- loss of bile salts e.g. Ileal resection
- diabetes: as part of metabolic syndrome
- oral contraception
132
How may a gallstone cause biliary colic ?.
Gallstone impacts on cystic duct or ampulla of vater
133
How may a gallstone cause acute cholecystitis ?
Distension of the gall bladder with subsequent necrosis and Ischaemia of mucosal wall
134
What is the presentation of biliary colic ?
- sudden epigastric/RUQ pain
- radiates ROUND to back
- persists for 15 mins then subsides spontaneously or with analgesia
- nausea or vomiting often accompany pain
135
Symptoms of chronic cholecystitis (caused by gall stones)
Vague abdominal discomfort, distension, nausea, flatulence and intolerance of fats
136
Differential of gall stones ?
- reflux
- peptic ulcer
- IBS
- relapsing pancreatitis
137
Investigations and findings for gallstones
- FBC - WCC likely raised
- liver enzymes often mildly abnormal
- ultrasound: thickened GB wall
138
Less common presentations of gallstones ?
- obstructive jaundice
- Cholangitis
- pancreatitis
- gallstone ileus
- empyema
139
Presentation of cholecystitis
- continuous epigastric/RUQ pain
- referred to right shoulder
- vomiting, fever
- local peritonism
- GB mass
140
What is the main difference between acute cholecystitis and biliary colic ?
Inflammatory component in cholecystitis (vomiting, fever, inc WCC)
141
What may occur if a gallstone becomes lodged in the common bile duct?
- obstructive jaundice
| - Cholangitis
142
What is murphys sign?
- Place hand in RUQ just below costal margin, mid clavicular line, ask patient to breathe in.
- pain and arrest in breathing suggests inflamed GB
* it is only positive if same test in lower quadrant does not produce same effect*
143
Symptoms of Cholangitis ?
- RUQ pain
- jaundice
- rigors
144
Treatment for Cholangitis ?
- Cefuroxime and metronidazole (broad spec)
| - surgical decompression of GB/endoscopic drainage
145
Symptoms of obstructive jaundice ?
- yellowing of skin
- paler stools
- darker urine
- pruritis
146
Treatment for common bile duct stones ?
- Cholecystectomy and exploration of CBD if GB present
- biliary sphincterectomy and endoscopic extraction of stone if GB previously removed
- biliary stent if stones irretrievable
147
How is hep A spread ?.
Faecal-oral
| Shellfish
148
Incubation period of hep A ?
2-6 weeks
149
Symptoms of hep A ?
- prodromal illnes: malaise, anorexia, nausea, arthralgia (flu like)
- jaundice , dark urine, pale stool, itch
- hepatomegaly, abdo pain, lymphadenopathy
*fever not actually common
150
Pathophysiology of hepatitis A ?
- Virus taken up by hepatocytes
- after uptake viral RNA uncoats and host ribosome bind to form polysome
- viral proteins then synthesised
- assembled virus particles them shed through biliary tree into faeces
151
Which parts of the world are high risk for hep A?
- Indian subcontinent
- africa
- South and Central America
- Middle East
152
Risk factors for hep A ?
- personal contact
- occupation e.g. Sewage worker
- travel to high risk areas
- male homosexuality with multiple partners
- IV drug use
-
153
Conditions presenting similarly to hep a ?
- other hepatitis
- acute HIV
- CMV
154
What specific antibody tests can be done for hepatitis A ?
- IgM: positive with onset of symptoms (3-6 weeks after exposure) test is sensitive and specific and remains positive for 3-6 months
- IgG: appears soon after IgM and remains detectable for life.
155
If IgG antibody for hep A is present but IgM is not, what does this suggest ?
Past infection or vaccination rather than active infection
156
What would be found in the liver enzymes in a hep A infection?
- ALT rises more than AST
| - alkaline phosphate rises with ALT and AST
157
Management of hep A infection?
- supportive I.e. Fluid, antiemetics, rest
- avoid alcohol until liver enzymes normal
- admit patients with severe systemic upset or intractable vomiting for rehydration and observation
158
Complications of acute hepatitis A infection ?
- Cholestatic hepatitis:
- death
- fulminant liver disease
159
Which countries is hep B most prevalent ?
- subsaharan africa
- most of Asia
- Pacific Islands
160
Most acute cases of hepatitis B in the UK are due to which cause ?
- IV drug use
| - sexual exposure
161
Presentation of acute Hepatitis B infection ?
- prodromal flu like illness
- starts insidiously with anorexia, nausea, ache in right upper abdomen
- icteric phase
- *similar to hep A except arthralgia and urticaria more common
162
Complications of hep b ?
- liver cirrhosis
- fulminant hepatic failure
- cholangiocarcinoma
163
Route if transmission of hepatitis b ?
- vertical: mother to baby
- sexual
- blood to blood I.e. Sharing needles
- transfusion associated infection (outside of UK)
164
Treatment of acute hepatitis B ?
- supportive
- avoid alcohol until liver enzymes normal
- stop any non essential meds
- chlorphenamine for itch but avoid in sever liver impairment
- antivirals in cases of fulminant
165
What investigations should be done in suspected hep b
- FBC
- bilirubin
- liver enzymes
- clotting
- ferritin
- lipid profile
- auto antibody screen
- caerulopasmin
- serological markers
- HCV and HIV test
166
Antibodies to HBsAg (I.e. Anti-HBs) imply what ?
Vaccination to hepatitis B only (no infection last or present)
167
Antibodies to hepatitis B core antigen (HBcAg) imply what ?
Past infection
168
Which serological marker is first to be present in hepatitis b infection ?
HBsAg
169
Presence of HBeAg implies what ?
High infectivity
170
What serological markers suggest chronic hep B infection .
- HBsAg positive for at least 6 months
OR
- positive HBsAg AND negative IgM HBcAg
171
Route if transmission of hep C ?
- mother to baby
- sex
- needles
172
Which factors are associated with more rapid progression to severe liver disease in hep c infection ?
- > 40 yrs
- alcohol consumption
- male gender
- co infection with HIV HBV
173
Presentation of hep c
- usually asymptomatic
- 20/30% present with jaundice or deranged liver
- non specific - anorexia, lethargy, abdo pain
174
What percentage of patients with hep c develop chronic infection ?
75-85%
175
Investigations in hep C ?
- anti HCV serology (+ve 3-9months after exposure)
- HCV PCR confirms ongoing infection
- liver biopsy if HCV PCR +ve to assess liver damage
- HCV genotype
176
Complications of hep c ?
- glomerulonephritis
- cryoglobulinaemia
- thyroiditis
- autoimmune hep
177
Which other virus does hepatitis D need in order to replicate ?.
Hep b
178
Affect of co infection with hep D ?
Acute liver failure/cirrhosis
179
What are the causes of hepatitis besides hepatitis viruses?
- alcohol
- drugs
- toxins
- EBV/CMV
- leptospirosis
- malaria
- syphilis
- yellow fever
- Wilson's disease
180
At what age is the highest incidence of appendicitis ?
10-20
However common at any age - most common surgical emergency
181
Pathogenesis of appendicitis
- Gut organisms invade the appendix wall after lumen obstruction by lymphoid hyperplasia, faecolith or filarial worms.
- leads to oedema, Ischaemia, necrosis and perforation
- cause linked to hygiene hypothesis-> impaired ability to prevent invasion
182
Symptoms of appendicitis
- perumbilical pain that localises to RIF
- anorexia *
- vomiting rarely predominant
- constipation usual but diarrhoea may occur
183
General signs seen in a patient with appendicitis ?
- tachycardia
- fever
- furred tongue, foetor oris
- lying still
- shallow breaths
In the RIF: guarding, rebound and percussion tenderness
184
What is McBurney's sign ?
Sign of acute appendicitis:
- pain at point 1/3 of way from ASIS to umbilicus
- suggests inflammation no longer limited to lumen of bowel (which localises pain poorly) is now irritating lining if peritoneum
- suggests increased likelihood of rupture
185
Investigations and findings in acute appendicitis
- bloods: CRP elevated, neutrophil leucocytosos
- ultrasound may help but appendix not always visualised
- CT has high diagnostic accuracy if unclear however may cause fatal delay
186
Treatment for appendicitis
- prompt appendectomy (if unsure examine often to avoid removing normal appendix)
- abx: metronidazole and cefuroxime
187
Complications of appendicitis
- perforation
| - appendix abscess
188
Pain from the fore gut radiates where ?
| Prox to 2nd part of duodenum
Epigastrium
189
Where does pain from mid gut radiate to ?
| Above to 2/3 along transverse colon
Perumbilical
190
Where does the hind gut radiate to ?
Supra public
191
Which conditions present similarly to appendicitis ?
- ectopic pregnancy
- UTI
- mesenteric adenitis
- Crohn's disease
- diverticulitis
- perforated ulcer
192
Cardinal features of intestinal obstruction ?
- vomiting
- colicky pain
- constipation
- distension
193
Causes of small bowl obstruction
- adhesions
| - hernias
194
Causes of large bowel obstruction ?
- constipation
- colorectal carcinoma
- diverticular stricture
- volvulus - sigmoid or caecal
195
Features if a small bowl obstruction
- vomiting occurs earlier
- distension is less
- pain higher in abdomen
196
Findings on AXR of small bowel obstruction a
- central gas shadows
- valvulae conniventes that completely cross lumen
- no gas in large bowel
197
Features specific to large bowel obstruction ?
- vomiting later
- absolute constipation more likely
- more distension
- pain more constant
198
Findings on AXR of large bowel obstruction
- peripheral gas shadows proximal to blockage
| - large bowel haustra do not cross all lumens width
199
What is an ileus and what are its clinical features ?
- a functional obstruction from reduced bowel motility
- no pain
- bowel sounds absent
200
What is a simple obstruction ?
- One obstruction point
| - no vascular compromise
201
What is a closed loop obstruction ?
- obstruction at 2 points
- forming a loop of grossly distended bowel
- risk if perforation
202
Which point in the bowel is most likely to perforate and why
.
Caecum - where bowel is thinnest and widest
203
What is a strangulated bowl obstruction ? What are its features?
- blood supply is compromised
- patient more ill than would expect
- sharper, more constant and localised pain
- peritonism = Cardinal sign
- fever with increased WCC and other signs of mesenteric Ischaemia
204
Which types of bowel obstruction always need surgery ?
- strangulation obstructions - emergency
- closed loop obstructions - emergency
- large bowel obstructions
205
What are the immediate actions once bowel obstruction is diagnosed ?
- NGT and IV fluids
- analgesia
- bloods: amylase, FBC, U&Es
- AXR
- erect CXR
- catheterise and monitor fluid status
206
What is meant by an irreducible hernia ?
- cannot be pushed back into the right place
| - refers to bowel hernias
207
What is meant by an incarceration hernia ?
Implies the contents of hernial sack are stuck inside by adhesions
208
When are GI hernias considered obstructed ?
If bowel contents cannot pass through them
209
When is a hernia considered strangulated ?
If Ischaemia occurs
210
Who do femoral hernias more commonly present in ?
Women, middle aged and elderly
211
Where are femoral hernias felt in relation to the pubic tubercle ?
Inferior and lateral
212
Where are inguinal hernias felt in relation to the pubic tubercle ?
Superior and medial
213
Pathogenesis of femoral hernia
- Bowel enters the femoral canal
- presents mass in upper medial thigh or above inguinal ligament
- mass points down the leg
214
Conditions presenting similarly to femoral hernia ?
- inguinal hernia
- enlarged cloquets node
- lipoma
- femoral aneurysm
215
Treatment for femoral hernia ?
Surgical repair (herniotomy- ligation and excision if of the sac & herniorrhaphy - repair of hernial defect)
216
What are direct inguinal hernias ?
Hernia push their way directly forward through the posterior wall of the inguinal canal, into a defect in the abdominal wall
217
Risk factors for direct inguinal hernia ?.
- male
- chronic cough
- constipation
- urinary obstruction
- heavy lifting
- Ascites
218
What are the borders of the inguinal canal:
- floor: inguinal ligament
- roof: fibres of transversalis, internal oblique
- anterior: external oblique aponeurosis & internal oblique for lat 1/4
- post: laterally= transversalis fascia, med= conjoint tendon
219
Which type of inguinal hernia is more likely to strangulate ?
Direct
220
What are indirect inguinal hernias ?
Hernia through patent processus vaginalis
221
What does tissue transglutaminase antibody test for ?
Coeliac disease
222
Which is more painful and why- intra abdominal bleed or bile leak ?
Bile leak as bile more irritant than blood
223
What day post op does wound dehiscence usually occur ?
Day 5
224
What is the most common post operative complication in older men ?
Acute urinary retention
225
Vague abdo symptoms e.g. Bloating and intermittent discomfort with steatorrhoea and weight loss is suspicious of which diagnosis ?
Coeliacs
Core Conditions
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