GI

Define refractory ascites.

(1) lack of response (<1.5 kg weight loss/week) to high-dose diuretics (400mg of spironolactone and 160mg of furosemide/day) while remaining compliant with a lo w - sodium diet, or (2) frequent ascites recurrence shortly after therapeutic large volume paracentesis (LVP)

Predictors of patient-assessed severity in IBS

Abdominal pain Belief 'something serious is wrong with body' Straining with defaecation Myalgias Urgency of defaecation Bloating

What is spontaneous bacterial peritonitis (SBP)?

Ascitic fluid PMN count >250 cells per mm 3 10-30% of hospitalised patients with ascites Mortality ~20%

IBS Drug Management

Bulk Forming i.e. Fybogel Osmotic Laxatives i.e. Movicol/Idrolax/Lactulose Antidepressants i.e. TCA :Amitriptylline/Clomipramine/Imipramine SSRI's: Citalopram/Fluoxetine Antidiarrhoeal ie Loperamide/Codeine Antispasmodics i.e. Mebeverine/Hyoscine Serotonergic i.e. 5HT3 & 5HT4 receptor agents

What are biofeedback techniques for IBS?

EMG or Manometry - monitor sphincter activity via surface electrodes during various manoeuvres By watching recordings of EMG activity or pressure responses patients may modify inappropriate responses (flushing lights / warning sounds) Short- and long-term improvement has been shown in up to 80% of patients using biofeedback

Differential diagnosis of focal liver lesion

Hepatocellular carcinoma Metastasis Cholangiocarcinoma Haemangioma Adenoma Focal nodular hyperplasia Cyst Abscess Others (e.g. angiosarcoma, angiomyolipoma)

Hyponatraemia in cirrhosis

Hypervolaemic ('dilutional') hyponatraemia: Na <130 mmol/L with ascites/oedema Prevalence Na <135 50%, <130 21-28% in cirrhotics Inpatients 57%, outpatients 40% High AVP due to arterial underfilling Impaired ability to excrete solutefree water (+ sodium avidity) Associated with increased risk of death, encephalopathy, worse outcome after OLT Tolvaptan - oral V2 receptor antagonist (collecting duct)- Increase free water excretion

IBS Management Philosophy

Identify Patient's Concerns Explain the nature of the condition Reassure: IBS is a recognised clinical entity Involve patient: symptoms can fluctuate; diet or stress may precipitate symptoms Provide continuity: ongoing review may be important to patient Set realistic expectations

Examples of functional bowel diseases

Irritable Bowel Syndrome (IBS) Functional Bloating Functional Constipation Functional Diarrhoea Unspecified Functional Bowel Disease

Prevalence of ascites in liver cirrhotics.

Present in ~10% of cirrhotics 50-70% develop ascites within 10 yrs

What is terlipressin?

Synthetic analogue of vasopressin Adjunct to endoscopic therapy Reduces failure to control bleeding Improves survival Adverse (ischaemic) events!

How do varices develop?

Varices develop when portal pressure (HVPG) >10mm Hg Variceal rupture occurs when HVPG >12mm Hg Progressively increased in diameter

Define acute pancreatitis

"Acute inflammatory process of the pancreas, with variable involvement of other regional tissues or remote organ systems"

What is 'non-specific' abdominal pain?

"Diagnosis" for patients in whom a specific cause is not found • Incidence may be as high as 40% of surgical admissions • Lower rates following more extensive investigations • Balance between level investigations and risk of serious pathology

What does extreme renal vasoconstriction indicate?

'functional' renal failure

GORD complications

(Oesophagitis) Peptic stricture Barrett's oesophagus Adenocarcinoma

Advantages of laparoscopic vs. open cholecystectomy

- Decreased post op pain - Earlier discharge - Earlier return to function - Improved cosmesis

Pros of barium swallow

- Defines anatomy clearly - Webs/rings - Frail pts - Motility abnormalities

Differential diagnoses for acute diverticulitis

- Infectious diarrhoea/toxic food poisoning - IBS - Diverticular disease - Colorectal cancer - IBD

Clinical features of biliary colic

- Intermittent epigastric/RUQ pain - Radiates to RUQ/scapula -Intense episodes which build up then subside - Brought on by fatty foods - Nausea and other assoc. symptoms - Potential findings: no fever, no SIR, +/- tender RUQ

Mild acute pancreatitis

- Minimal organ dysfunction - Uneventful recovery

Local complications of acute pancreatitis

- Peripancreatic fluid collection - Pancreatic necrosis - Pancreatic abscess - Infected necrosis - Pseudocyst - Biliary/gastric obstruction

General complications of acute pancreatitis

- Respiratory failure - Renal failure - Circulatory failure - Malnutrition

Define cirrhosis

- Response to chronic long term injury - 'Final common pathway' of damaging agents - Scarring + hepatocyte regeneration - ?reversible - Asymptommatic presentation to death

Treatment of a fissure-in-ano

- aims to reduce sphincter tone Medical therapy- GTN cream Surgical therapy- internal sphincterotomy

Prognosis of Hep C

- alcohol provides a major contribution during later stages of disease (15+ yrs) - obesity provides a major contribution to developing cirrhosis at 35+ yrs after infection - Survival rate lower in pts with decompensated cirrhosis

Features of Barrett's oesophagus

- columnar type mucosa in lower oesophagus commonest in obese men >50 Intestinal metaplasia asymptommatic pre-malignant- low grade dysplasia, high grade dysplasia, adenocarcinoma observation ?ablation ?role for drug therapy (aspirin, PPI)

Pros of endoscopy

- direct visualisation of mucosa - careful assessment of mucosal detail - subtle abnormalities detected - biopsies- histology/virology - therapeutic interventions

Features of acute cholecystitis pain

- epigastric/upper abdominal - maximally tender in RUQ - intermittent vs. constant

Clinical features of fistula in ano

- generally develops from neglected perianal sepsis - connection between anal canal and perianal skin - persistant pain and discharge

How is the disruption of bacteria related to IBD?

- intestinal segments with increased bacterial loads - abnormal microbial composition - serologic and T cell responses to enteric microbial antigens - increased mucosal-assoc bacteria and increased mucosal invasion and translocation in IBD

Role of pathology in GI neoplasia

- knowledge of mutations - sporadic vs. germline (inherited) mutations- risk of other malignancies, assessment of risk to other family members - "Personalised medicine" - Predicting the likely response to targeted therapy i.e. cetruximab - mismatch repair gene mutations

What is a fissure-in-ano?

- linear tear in anoderm (midline posteriorly usually); chronic= ischaemia secondary to internal sphincter spasm - often follows an episode of constipation

What is oesophageal manometry used for?

- measures intra-luminal pressures and coordination - useful for symptoms when structural abnormality has been excluded - Dysphagia and motility abnormalities -assessment of upper and lower sphincters

Cons of barium swallow

- no biopsies - no therapeutic interventions - mucosal lesions may be missed - often need F/U endoscopy - radiation

Clinical features of a fissure-in-ano

- presents with pain following defaecation and bright red rectal bleeding

What are haemorrhoids?

- symptommatic haemorrhoidal cushions - arterioles, venules, anteriolar-venular communications - Slide down or prolapse, become congested and bleed

When should oesophageal manometry be used?

- unexplained dysphagia after radiology and endoscopy - pre-op assessment of pts considered for anti-reflux surgery - investigation of NCCP

Cons of endoscopy

-invasive -pt not fit enough -cost -not good for motility abnormalities -usually normal in GORD

Epidemiology of Crohn's

0.1% f:m= 1.3:1 Age: 20-30 and 50-60 (BIMODAL) Ashkenazi Jews Western Europe, North America

What is the prevalence of IBDs in Western Europe?

0.5%

Hep E prognosis

1-3% mortality pregnant women more susceptible illness severity increases with age

Chemotherapy for colorectal cancer

1. 5-fluorouracil based regimens - now capecitabine (TS inhibitor) 2. Combination therapy (CAPOX) Capecitabine (thymidylate synthase inhibitor) + oxaliplatin 3. 2nd line agents Cetuximab -mab to epidermal growth factor receptor Bevacizumab - mab to vascular endothelial growth factor Temozolomide

Hep B Genotypes

1. A NW Europe, N America, Central Africa 2. B SE Asia, Japan, China 3. C SE Asia, Japan China 4. D Mediterranean, Middle East, N America 5. E Africa 6. F American Natives, Polynesia, Central and South America 7. G USA, France

Management of biliary colic

1. Conservative- low fat diet 2. Medical- oral dissolution therapy (ursodeoxycholic acid), lithotripsy 3. Surgical- cholecystectomy

Resuscitation for acute variceal bleed in cirrhotic patient

1. Consider intubation 2. High flow oxygen 3. IV access 4. Blood transfusion 5. Antibiotics 6. Terlipressin/somatostatin 7. Gastroscopy ASAP but within 24hrs

What are the alternating features of IBS

1. Constipation: dry hard pellets/ribbon stools 2. Diarrhoea: several loose stools especially in morning or after meals

What is the role of the enteric nervous system in IBS?

1. Controls intestinal motility and secretory function by semi-autonomous and independent methods 2. Neurotransmitters i.e. 5-HT

Treatment for all forms of cirrhosis.

1. Dependant on aetiology 2. Screen and treat complications 3. Consider liver transplantation if poor prognosis

What defines a severe attack of UC?

1. Diarrhea >/- 6 with visible blood + - pulse rate >90 or temp>37.8 or Haemoglobin <10.5 or ESR >30

Causes of dysphagia

1. Diseases of mouth/tongue/throat 2. Mechanical lesions- extrinsic and intrinsic (stricture, lower oesophageal rings/webs/pouches) 3. Neuromuscular- pharyngeal (bulbar palsy, MG) or motility (primary vs. secon) 4. Eosinophilic oesophagitis- asthma

Biliary colic investigations

1. FBC- WCC 2. LFTs 3. Amylase 4. USS

What are some 'hidden areas' to consider when examining the GI system?

1. Hernial orifices 2. Genitalia 3. PR 4. Pulse/BP/Temp

IBS Investigations

1. Imaging- Barium enema, Upper abdominal ± pelvic USS, Abdominal CT scan 2. Colonoscopy or-opy & Bx 3. Examination of stool- Stool microscopy, culture, C. difficile, Stool weight / volume 4. Blood studies- haematology, biochemistry, CRP, ESR, Coeliac serology 5. Colonic Transit & Motility studies

Phases of Hep B infection

1. Immune tolerant phase 2. Immune active phase 3. After HBeAg seroconversion can go to 4.5. or 6. 4. Inactive phase 5. HbeAg neg hepatitis 6. Spontaneous clearance of HBsAg

CBD investigations

1. LFTs (elevated bilirubin, ALP) 2. Coagulation (prothrombin time- reduced absorption of fat soluble vitamins, especially K) 3. ?Gallstones- USS +/- MRCP +/- ERCP 4. ?Pancreatic cancer- USS +/- CT

Maintenance treatment in UC

1. NO corticosteroids in maintenance treatment 2. 5-ASA i.e. sulphasalazine, mesalazine, olsalazine 3. Immunosuppressants i.e. azathiprine, cyclosporin are used in difficult refractory disease

What is the function of commensal flora?

1. Nutrient processing 2. Absorption 3. Development of mucosal immune system 4. Angiogenesis 5. Epithelial renewal

Complications of cirrhosis

1. Oesophageal varices- propranolol 20mg bd or carvedilol od for prophylaxis, next step= variceal band ligation; SCREENING ENDOSCOPIES 2. HCC- HCV and HBV major risk factors- curative treatment options; AFP AND USS EVERY 6 MONTHS

What are functional GI disorders?

1. Persistent and unexplained symptoms 2. Absence of structural abnormality 3. Absence of pathological processes 4. Disordered physiological function

Management of acute cholangitis

1. Resuscitate- treat sepsis i.e. IV fluids, antibiotics, close monitoring 2. ERCP- sphincterotomy +/- stent 3. Cholecystectomy +/- exploration of CBD (not acutely)

What are the principles of treatment in Crohn's disease?

1. Resuscitation- correct metabolic and nutritional disturbances 2. Treat active disease- medical or surgical 3. Maintenance of remission

Normal function of oesophagus

1. Swallowing via striated muscle 2. Relaxation of UOS 3. Food enters oesophagus- smooth muscle- outer longitudinal, inner circular layer 4. Triggers primary peristaltic wave 5. LOS relaxes as soon as swallow initiated 6. Allows food into stomach

What is the role of intervention in chronic pancreatitis?

1. To relieve symptoms 2. To treat complications 3. Doubt in diagnosis

What are the goals of treatment in UC?

1. Treat active disease 2. Maintenance of remission

Types of abdominal pain

1. Visceral Pain- innervated by autonomic nervous system (dull ache, poorly localised, nausea; stretching, distension, inflammation, ischaemia) 2. Parietal Pain- innervated by somatic nervous system (severe, well localised, persistent) 3. Referred Pain- perceived at a site distant to stimulus

Investigations for acute cholangitis

1. WBC/coag 2. LFTs/amylase 3. Blood culture 4. USS

Acute cholecystitis investigations

1. WCC- neutrophilia 2. LFTs- normal 3. USS- thick walled/odematous GB

Aetiology of gallstones

1. cholesterol (20%)- obesity, pregnancy, age, FHx, OCP, low fibre, terminal ileal disease 2. Pigmented stones (5%)- haemolytic anaemia 3. Mixed (75%)- calcium bilirubinate and cholesterol

Examination features of acute cholangitis

1. looks ill 2. SIRS/septic 3. Icteric 4. Tender RUQ

Aims of cirrhosis investigations

1.Determine the presence of cirrhosis, biopsy "gold" standard 2. Find the cause 3. Identify and screen for complications (varices and cancer)

How many parts of the duodenum are there?

1= Superior (intraperitoneal; mesentery) 2= Descending (retroperitoneal) 3= Inferior (retroperitoneal; post to SMA) 4= Ascending (retroperitoneal)

Prognosis of Type 1 HRS

2 week mortality rate as high as 80% in untreated, with only 10% surviving for 3 months

Mortality of first variceal bleed

20%

Most common age group presenting with IBS

20-40

What proportion of liver cirrhosis patients present with bleeding or HE?

25%

Epidemiology of acute pancreatitis

3% of all admissions with abdominal pain* • 80% spontaneous resolution • 20% develop complications

Incidence of anal carcinoma (UK)

300 cases annually (1.5% of all malignant colorectal disease)

Disadvantages of colectomy in UC

38% short term complications Pouch excision c. 1% pa Physicians can increase the risk of surgical complications

Treatment for SBP in cirrhotic patients

3rd generation cephalosporins and albumin are treatment of choice 70% recurrence at 1 year, so longterm secondary prophylaxis with norfloxacin 400mg od Primary prophylaxis if low ascitic albumin (<10 g/L) Always consider referral for liver transplant

Prevalence of coeliac disease in 1st degree relatives

5-15% **No increased risk in 2nd degree relatives**

What is the mean survival for stenting in jaundice?

5-8 months

What are the GI receptors involved in IBS impaired motility?

5-HT4 agonists accelerate colonic transit and emptying; triggers peristaltic reflex and colonic mass movement

Clinical features of rectal prolapse

50% will have faecal incontinence

What proportion of liver cirrhosis patients present with ascites and jaundice?

50-75%

Prognosis for anal carcinoma

65-80% 5yr survival

Treatment of SBBO in Coeliac patients

7-10/7 course of • Co-amoxiclav + Metronidazole • Cephalexin + Co-trimoxazole • Gentamicin + Metronidazole

How is albumin used to treat cirrhotic patients?

70% of total plasma oncotic activity Prolonged half-life High capacity molecule transport (cations/anions) Free radical scavenging - thiol gps Modulatory effect on capillary permeability/ rheology Modulatory effect on neutrophil adhesion/ activation Nitric oxide binding Drug binding Improves renal blood flow autoregulation in patients with acute decompensation of cirrhosis and AKI

Features of HBV after HBeAg seroconversion

70%- low, inactive replicative state 10-30%= reactivation to eAg neg hepatitis (immune escape) 10%- HBeAg neg hepatitis (ALT increase, HBV DNA >2000)

Where is 5-HT found in the body?

95% in GI tract 5% in CNS

Treatment of anal cancer

<2cm= local excision >2cm=chemo-irradiation +/- abdominoperianal resection

Amsterdam criteria for defining HNPCC

>3 family member with histologically proven colorectal cancer One relative a first degree relative of the other two >2 generations affected Age at onset <50yrs in at least one family member Uterine cancer in one or more relatives acceptable as part of a 3 member family

Modified Dukes Classification for staging colorectal cancer

A Limited to bowel wall B Through full thickness bowel wall C1 Regional lymph nodes involved C2 Apical lymph node involved

Why do clinicians perform DREs?

A digital rectal examination enables an observant clinician to identify several disease processes pertaining to the rectum. Often incorporated in a focused urologic, gynecologic, gastrointestinal, and neurologic examination. Disease processes that may be investigated with a digital rectal examination include, but are not limited to, the following: PR bleeding Bowel changes Palpable mass Foreign body Trauma survey Urinary changes Neurologic deficits

Management of peptic perforation

ABC iv access- cyrstalloids, colloids, blood define circulatory status define co-morbidity blood tests; FBC, U&E's, LFT's, clotting Cross-match blood Intensive monitoring Early endoscopy HP eradication PPI's Surgery

Surveillance for HCC in cirrhosis

AFP Liver USS All cirrhotics, non-cirrhotic African/Asian HBV carriers

Pathology of anal carcinoma

AIN (anal intra-epithelial neoplasia) Squamous Adenocarcinoma Basiloid Small cell carcinoma Malignant melanoma

Treatment of anal carcinoma

AIN1&2 - Observe, often settles AIN3 - Surveillance with magnifying anoscopy and biopsy Local excision for invasive carcinoma T1/T2 tumours Combined chemo-radiation for invasive carcinoma i.e. 5FU/mitomycin C and radiotherapy Abdomino-perineal excision - salvage procedure

Features of immune active phase of HBV

ALT increased HBV DNA reduction as host immune system recognises and clears infected hepatocytes Histologically- active inflammation Phase may last from months to many years HBeAg seroconversion to anti-HBe represents end of phase and reduced risk of adverse outcome

Investigations in primary sclerosing cholangitis.

ANCA

Define acute abdominal pain.

Abdominal pain of less than 1 week duration requiring admission to hospital, which has not been previously investigated or treated

Symptoms of ileocaecum Crohn's disease.

Abdominal pain, diarrhea, fever, abdominal mass, enteric fistulas

Epithelium of the duodenum, ileum, jejunum?

Absorptive- mucosa arranged into villi with short glands

Epithelium of the colon, rectum?

Absorptive/Protective- closely packed straight tubular glands

Pathophysiology of hepatic encephalopathy

Accumulation of gut-derived neurotoxic substances (e.g. ammonia), astrocyte damage, impaired neurotransmitter function

Clinical features of anal sepsis

Acute onset perianal pain assoc. with swelling - arises from anal glands

Pancreatic diseases

Acute pancreatitis Chronic pancreatitis Pancreatic tumours

Differences between acute and chronic Hep B infections

Acute- no good evidence for the use of antivirals, not many cases become fulminant Chronic- use antivirals

Levels of adequacy of excision

Adequacy of excision: • R0 = local excision complete • R1 = microscopic disease present at margin(s) • R2 = macroscopic disease present at margins(s)

Acute cholecystitis management

Admit and monitor 1. NBM 2. resuscitate with IV fluids 3. Analgesia +/- antiemetic 4. Antibiotics +/- ?Operate

Epidemiology of gastric-duodenal ulcers

Affects 10% of population Male/female 5:1-2:1 Commonest in blood group A+; +ve family Hx

Aetiological factors of colorectal cancer

Age Western Diet i.e. high in fat, red meat and total energy,low in fibre, fruit and veg, high stool pH, unknown combination of factors Lifestyle factors- smoking in men, lack of exercise, beer (rectal cancer) Inflammatory bowel disease- pan-ulcerative colitis, Crohn's disease Genetic predisposition- dominant gene disorders

Diagnosis of acute pancreatitis

Age - 40-50 years • Acute, severe, upper abdominal pain - back, with nausea/vomiting • Epigastric tenderness • 3-4 times elevated serum amylase

Risk factors for NSAID-induced ulcers

Age >60 yr (atrophic gastritis) Past history of PUD Past history of adverse event with NSAID's Concomitant corticosteroid use High-dose or multiple NSAID's Individual NSAID - lower with ibuprofen

Risk factors for oesophageal cancer

Alcohol Smoking Reflux Obesity

Elective presentations of colorectal cancer.

Altered bowel habit Rectal bleeding Colicky pain Unexplained anaemia Anorexia/wt loss/malaise Flatulence

Leg signs of cirrhosis

Ankle oedema Bruising

GI Symptoms to ask about

Appetite and Satiety Swallowing N&V Heartburn/indigestion/reflux Belching, bloating Abdominal Pain Constipation + diarrhoea Bleeding/mucous PR Jaundice

Epidemiology of Hep B

Approximately 400 million individuals chronically infected Responsible for approx 100,000 deaths per year- complications of cirrhosis or hepatocellular carcinoma Over 50% of deaths related to HBV are in Africa and South-East Asia About 8 % of deaths related to HBV are in Europe

CT characteristics of hepatocellular carcinoma

Arterial phase (enhancement) Portal venous phase (washout) Portal vein thrombosis

Causes of abdominal infarction

Arterial- embolism, thrombosis, extrinsic compression Venous- thrombosis, external compression Shock Vasoconstrictor drugs

Extra-intestinal manifestations of IBD

Arthritis/arthropathy Skin disease i.e. erythema nodosum, pyeoderma gangrenosum Eyes: iritis Hepatibiliary i.e. primary sclerosing cholangitis, gallstones Renal oxalate stones Venous thrombo-embolic disease

How does the WHO classify H. pylori?

As a class 1 carcinogen

When should a liver transplant be considered in a cirrhotic patient?

Ascites - 50% survive 2 years Refractory ascites - 50% survive 6 months Liver transplant - 85% survive 2 years

Types of specimens examined by pathologists

Autopsies- declining number requested, diagnosis, effects of treatment, teaching and audit Surgical resections- neoplastic disease, non-neoplastic disease Biopsies- endoscopy, laparoscopy and laparotomy, percutaneous, by direct vision or ultrasound guidance Cytology- fine needle aspiration, brushing, fluids (aspirated, washings) Frozen sections- for rapid diagnosis, unexpected findings during surgery that may influence patient management

Assessing severity of acute pancreatitis

BMI > 30 • Pleural effusion on CXR • CRP

Investigations for diverticular disease

Barium enema Colonoscopy

Oesophageal radiology investigations

Barium swallow • Water sol swallow • Endoscopy • Endoscopic US • CT - for staging • Intervention

Causes of obstructive jaundice

Benign i.e. duct calculus Malignant i.e. cholangiocarcinoma, pancreatic carcinoma, metastatic tumours in liver or lymph nodes

What is the best test for colonic cancer?

Best test: colonoscopy Best radiological test: CT colonography ......after diagnosis Colon: CT Rectum: MRI

Differentials for acute pancreatitis

Biliary colic, Perforated peptic ulcer, Acute mesenteric ischaemia, Acute MI, Basal pneumonia

Complications of endoscopic retrograde cholangio-pancreatography

Bleeding Cholangitis Pancreatitis Perforation

Clinical features of haemorrhoids

Bleeding: bright red, on toilet paper, often painless Discomfort Prolapse Mucous discharge/pruritus Thrombosis: acutely painful

Diagnostic process for hepatic encephalopathy

Blood ammonia, EEG, critical flicker frequency

Investigations in alpha 1 antitrypsin.

Blood level and phenotype (ZZ)

Radiology intervention for colon cancer

Bowel stents- when patient too ill for surgery or tumour inoperable

Types of tumours in FAP

CHRPE Duodenal polyposis colorectal adenomatous polyposis Mesenteric desmoid tumour Osteomata

How do NSAID's induce peptic ulcer disease?

COX pathway Prostaglandins stimulate bicarbonate and mucus secretion and increase mucosal blood flow Anti-inflammatory effect by inhibiting cyclo-oxygenase activity Depletion of mucosal prostaglandins results in mucosal injury

Investigations for focal liver lesion

CT MRI with contrast Liver biopsy- reserved for inconclusive cases

Investigations in Wilson's disease.

Caeruloplasmin, Cu in blood or urine

Features of HBeAg negative hepatitis of HBV

Can be "unmasked" following HBeAg seroconversion Immune escape from inactive phase HBV DNA lower than HBeAg state- 2000- 2 million IU/ml Mutations in basal core promoter region (BCP) may play a role Pre-core mutation less certain

Clinical features of acute cholangitis

Charcot's Triad- RUQ pain, fever (+/- rigors), jaundice

How is the prognosis for liver cirrhosis determined?

Child-Pugh Score Patients with Child-Pugh score > 8 have a predicted mortality of 50% at 1 year, therefore transplantation considered in such patients

Define chronic pancreatitis

Chronic pancreatitis is defined as a continuing inflammatory disease of the pancreas characterised by irreversible, morphologic change that typically causes pain or permanent loss of function or both.

Pathophysiology of AKI in cirrhotic patients/

Cirrhotics have chronic low-grade renal hypoperfusion, circulatory dysfunction, cardiomyopathy Inpatients susceptible to multiple '2nd hits' Spontaneous bacterial peritonitis (SBP) GI bleeds (26%); large volume paracentesis Majority of AKI develops in outpatients Diuretics, lactulose

Preoperative staging of colorectal cancer

Clinical- Hx and exam, digital and sigmoidoscopy +/- EUA Imaging- CT scan- chest, abdo, pelvis MRI pelvis US_ liver and rectal Suspected mets workup- USS of liver + liver MRI + CT protography/arteriography CT/PET scan Tumour markers- CEA

Hand signs of cirrhosis

Clubbing Polished nails Leukonychia Dupuytren's contracture Palmar erythema Tremor Bruising

Define coeliac disease.

Coeliac disease is a common digestive condition where a person has an adverse reaction to gluten.

Pathogenesis of Coeliac disease

Coeliac disease is an autoimmune condition which results in damage to the lining villi of the small intestine. The villi increase the absorptive surface of the small bowel and contain blood vessels to absorb nutrients. • When the villi are damaged this results in malabsorption of vitamins, minerals, calcium, carbohydrates, protein and fats NOT allergy or an intolerance to gluten.

Diuretic therapy for cirrhotic ascites.

Combination - aldosterone antagonist + loop diuretic Adjust dose every 3-5 days Maximum spironolactone 400mg/ furosemide 160mg No more than 0.5kg/day weight loss Complications - electrolytes, acute kidney injury, encephalopathy, painful gynaecomastia Compliance/ response - spot urinary Na:K ratio > 1

Prevalence of AKI in cirrhosis

Common (~20% of hospitalizations) High mortality (55-91%)

How can you reduce the rate of nausea associated with methotrexate use in Crohn's?

Concomitant daily folic acid and metoclopramide/onsansetron peri-injection

Why do radiologists do PTC?

Confirms obstruction • Defines nature and position of lesion

Morphological abnormalities of the pancreas

Congenital- Pancreas divisum / Annular pancreas Trauma- Blunt or penetrating trauma Inflammatory- Acute or chronic pancreatitis Tumours- Benign or malignant neoplasms

Treatment of haemorrhoids

Conservative management: high fibre diet Injection sclerotherapy Rubber band ligation Infra-red photocoagulation Haemorrhoidectomy: excision of pile mass

Crohn's treatment

Corticosteroids Budesonide (for ileocaecal disease) High dose 5-ASA (mesalazine) Metronidazole for perianal disease TNFa antibody Immunosuppressive med i.e. azathioprine Exclusive polymeric diet IBD specialist nurse support Helpline phone number NACC info pack Stop smoking Genetics study? Follow up at 2-3weeks and then 4 months, 7 months

Differential diagnoses of UC

Crohn's Ischaemic colitis Infective colitis Drug-induced colitis Microscopic colitis Colo-rectal neoplasm/polyp Diverticular disease IBS

Pathological features of ulcerative colitis

Crypt abscesses

Pathological features of Coeliac disease

Crypt hyperplasia Intra-epithelial lymphocytes Villous atrophy Excess lymphocytes and plasma cells in lamina propria

Role of surgery in chronic pancreatitis

Decompression of pancreatic/bile duct - Peustow's lateral pancreatico-jejunostomy - Hepatico-jejunostomy • Resectional surgery - Whipples pancreatico-duodenectomy - Distal pancreatectomy • Combined - Frey's surgery - Beger's procedure

Define achalasia

Degenerative lesion of inhibitory innervation Failure of LOS to relax Aperistalsis of oesophageal body

What is the role of pathology in suspected GI neoplasia?

Diagnosis of non-neoplastic conditions mimicking neoplasia Diagnosis and assessment of pre-malignant lesions Confirmation of neoplasia When confirmed- benign or malignant? primary vs. secondary? Following surgical resection- grade and stage? Tumour completely excised? response to neo-adjuvant therapy, prognostic or predictive factors?

Diagnosis for ascites in cirrhotic pts.

Diagnostic tap (albumin, WCC, micro, cyto) High serum-ascites albumin gradient >11 mmol/L

Symptoms of other Crohn's disease.

Diarrhea, abdominal pain, weight loss, arthralgias, jaundice, oral ulcerations, conjunctivitis

Side effects of H. pylori treatment

Diarrhoea 30-50% of patients -mild Clostridium difficile colitis can occur Metronidazole: metallic taste, flushing/vomiting if taken with alcohol Nausea, vomiting Abdominal cramps Headaches Rash

Symptoms of SBBO in Coeliac patients

Diarrhoea > Pain > Weight loss > Bloating > Flatulence > Nausea > Steatorrhoea • Nutritional deficiencies • Vit D (tetany) > Vit A (night blindness) > Cobalamin (neuropathy) > Vit B12 (macrocytosis)

Treatment of eosinophilic oesophagitis

Diet - elimination (egg, wheat, milk, nuts, soya, fish) Drugs - PPI, topical steroid Dilatation - for strictures

Epidemiology of colorectal cancer

Disease of westernised societies 2nd Commonest cause of cancer death 3rd commonest incident male cancer (after lung & prostate) 3rd commonest incident female cancer (after breast & lung) 15% of all male cancers, 12% of all female cancers 37,500 cases and 21,000 deaths annually in UK 3,617 cases and 1565 deaths in Scotland Colon F>M; Rectum M>F Peak age 75-79 yrs (age-specific mortality increases exponentially with age) Age-standardised Scottish incidence - 66.6Male, 42.1Female /100,000 (EASR) Lifetime risk - 5.1%

Aetiology of IBD

Disruption of commensal flora Smoking- detrimental in Crohn's, protective in UC Positive family history- Crohn's

Complications of diverticular disease

Diverticulitis i.e. LIF pain, tenderness, guarding, fever and leucocytosis Pericolic abscess Perforation: peritonitis Fistula i.e. colovesical Haemorrhage Intestinal obstruction i.e. small or large bowel

IBS Management

Doctor - patient relationship History and examination Appropriate investigation Explanation and reassurance Symptom control

Consequences of H. pylori infection

Duodenal ulcer Gastric ulcer Gastric cancer MALT non-ulcer dyspepsia NSAID-induced gastropathy GORD

Where does the duodenum transition to the jejunum?

Duodenojejunal flexure

Symptoms of IBS

Dyspepsia- ulcer-like, reflux, N&V, satiety and fullness Tiredness Backache Dyspareunia Urinary frequency Headache Nocturia Sleep disorder Fibromyalgia

Oesophageal symptoms

Dysphagia Globus Odynophagia Heartburn Acid regurgitation Waterbrash Chest Pain Food regurgitation Cough Dysphonia

Early vs. Late Cholecystitis Surgery

Early definitive treatment same episode (avoids readmission) avoid complications (e.g. empyema) "difficult operation?" increased risk of infection/wound complications Late further elective admission (>6 weeks) risk of recurrent problems / readmission in interim easier to perform?

Gynaecological causes of acute abdominal pain

Ectopic pregnancy • Ovarian cyst • Pelvic Inflammatory Disease • Mittelschmerz

Investigations in viral hepatitis.

Either viral proteins or nucleic acids and immunological reaction against the virus

Risk factors for rectal prolapse

Elderly Uterine prolapse Obstetric trauma Previous hysterectomy

Surgical treatment options for colorectal carcinoma

Endoscopic removal of small/moderate adenomas Piecemeal endoscopic snare polypectomy

Investigations for gastric cancer

Endoscopic ultrasound CT (M staging) Laparoscopy/ultrasound

Investigations for peptic ulcer disease

Endoscopy Barium meal examination HP status Re-endoscopy important if there is suspicion of malignant ulcer (gastric)

Diagnosis of eosinophilic oesophagitis

Endoscopy - furrows, rings, exudates, strictures Biopsy for diagnosis

Stomach and duodenum radiology investigations

Endoscopy- best test CT for staging of tumours CXR for perforation WS swallow for perforation i.e. post-op leak

Radiological signs of HCC

Enhancing mass with contrast (vascularised) Cirrhotic liver

Pathogenesis of IBD

Environmental changes of last century and the not yet adapted genetic background of a sub-fraction of the population

Hep E transmission

Epidemics- faecally contaminated drinking water Minimal person-person transmission

Clinical features of peptic ulcer disease

Epigastric pain- relief by food nausea fullness bloating hunger pain

Clinical features of acute cholecystitis

Epigastric/RUQ pain +/- biliary colic symptoms Radiates to shoulder/right scapula Systemic upset- anorexia, nausea, vomiting, fever

Epidemiology of Ulcerative colitis

Equal sexes 20-40y/o Ashkenazi Jews Western Europe, North America Incidence rates are steady last 30 years

General Treatment for hepatic encephalopathy

Exclude non-hepatic causes of altered mental function (e.g. alcohol w/d, hypoglycaemia) Identify and treat precipitating factors Lactulose side effects and non compliance, UGI bleed, constipation, sepsis, diuretics, TIPSS, etc Maintain energy, fluid, and electrolyte balance Fall precautions Avoid CNS depressants Consider prophylactic intubation for grade 3 or 4 HE (aspiration) and transfer to ITU ICP monitoring

Functional abnormalities of the pancreas

Exocrine insufficiency- chronic pancreatitis Endocrine insufficiency- diabetes mellitus Functioning tumours- insulinoma, gastrinoma

Crohn's Investigations

FBC CRP, ESR LFT U&E Albumin Stool MC&S and CDT Ileocolonoscopy Small bowel MRI ?TPMT ?faecal calprotectin

What are the indications for anti-reflux surgery?

Failure of medical treatment Reflux stricture ?Barrett's ulcer/columnarisation

Hereditary forms of colorectal cancer

Familial adenomatous polyposis Hereditary nonpolyposis colorectal cancer

Define globus.

Feeling of a lump or tickle in back of throat Does NOT interfere with swallowing - CONSTANT, less noticeable when eating

Investigations in haemochromatosis.

Ferritin, Iron, TIBC, Genetic testing

Radiology intervention for oesophageal dysphagia/carcinoma.

Flamingo wallstent

Support treatment for acute pancreatitis

Fluid resuscitation • Analgesia • Nutrition - Nil by mouth initially - Feeding - Dietician • Monitor early warning signs • Organ dysfunction • Critical care support

IBS differential diagnoses

Food intolerance Infection Giardiasis, Amoebiasis, TB Inflammatory bowel disease Bacterial overgrowth Diverticular disease Colon cancer Bile salt malabsorption CHO malabsorption Lactose /Fructose /Sucrose Hormonal syndromes medullary thyroid ca gastrinoma /Vipoma glucagonoma Food intolerance Infection Giardiasis, Amoebiasis, TB Inflammatory bowel disease Bacterial overgrowth Diverticular disease Colon cancer Bile salt malabsorption Rarer types of colitis Rarer types of colitis Gold colitis Gold colitis Collagenous Collagenous / Lymphocytic / Lymphocytic Pseudo -obstruction obstruction Myopathy Myopathy Neuropathy

Causes of mucosal damage

GI SECRETIONS Acid / pepsin biliary & pancreatic • ISCHAEMIA • DRUGS NSAIDs, antibiotics, steroids chemotherapy e.g. 5-Fluoro- uracil • IMMUNOLOGICAL Coeliac disease, ?ulcerative colitis, ?Crohn's disease • INFECTION Helicobacter, Salmonella, Shigella, E. coli, C. difficile, Viruses, Candida • RADIATION • TRAUMA Surgical resection, endoscopy • IDIOPATHIC

Primary disorders of oesophageal motility

GORD Disorders of impaired LOS relaxation i.e. Achalasia, Oesophagogastric junction outflow obstruction Major disorders of peristalsis- i.e. Absent contractility, Distal oesophageal spasm, Jackhammer oesophagus Minor disorders of peristalsis- i.e. Ineffective oesophageal motility Fragmented peristalsis

Types of stomach tumours

Gastric adenocarcinoma (incidence falling) Gastric lymphoma (<5% of gastric malignancy) GISTs (mostly benign leiomyomas but can bleed) Carcinoid tumours

Medical causes of acute abdominal pain

Gastrointestinal • Genitourinary • Cardiovascular • Thoracic • Neurological • Haematological • Endocrine • Metabolic • Infective

GI Systematic Enquiry

General: weight loss, fever, sweats, fatigue Resp Cardio Neuro MSK

Types of peritonitis

Generalised- primary vs. secondary Localised- underlying visceral inflammation

Epidemiology of hepatocellular carcinoma

Global health problem 6th most common cancer Commonest 1o liver cancer (90%) Incidence rising in Europe and USA Males > females, average age 66 in UK Commonest cause of death in cirrhotics Incidence 1-8%/yr 5 year survival dismal > 80% of patients present with multifocal HCC Lack of biomarkers that can detect resectable disease Highly resistant to systemic chemotherapy Multidisciplinary team management

Causes of peptic ulcer

H.Pylori (>90% DU's, >70% GU's) NSAID's (Non-Selective NSAIDs deplete mucosal defense) Stress - Burn injury/Sepsis/prolonged hospitalization Smoking - causes increased risk / delayed healing Rare: Acid-pepsin versus mucosal resistance - Zollinger Ellison syndrome - Excess gastrin - gastrinoma

Investigations of SBBO in Coeliac patients

H2 Lactose / Glucose breath test

Features of immune tolerant phase of HBV

HBeAg positive Normal ALT HBV DNA > 20,000 IU/ml No histological evidence of inflammation or fibrosis Can last for more than 30 years Lots of HBV integration into host DNA

What are markers of HBV disease?

HBeAg- high replication HBV DNA ALT

Define chronic hepatitis B

HBsAg positive > 6months

Transplantation as treatment option for HCV

HCV commonest indication worldwide for transplantation Disease recurrence is universal Treatment of HCV post-OLT is less effective than in native liver

Types of cirrhosis with high incidence of HCC

Haemochromatosis HCV HBV Alcohol with HCV

List of peri-anal conditions

Haemorrhoids Anal fissure Anal sepsis

What are the typical symptoms of GORD?

Heartburn/acid regurgitation/waterbrash

Causes of non-obstructive jaundice

Hepatitis Cirrhosis Metastatic disease

Abdominal signs of cirrhosis

Hepatomegaly Splenomegaly Ascites Dilated Veins Testicular Atrophy Umbilical hernia

Aetiology of peptic ulcer

Hereditary O blood group Smoking- increases risk of GU and DU, more likely to cause complications in established ulcers, less likely to promote healing

Conservative management of diverticular disease

High fibre diet, antispasmodics

Investigations for colorectal cancer

History and clinical examination Digital rectal examination (no FOBT) Rigid sigmoidoscopy and biopsy Colonoscopy Barium enema and flexible sigmoidoscopy All patients with proven CRC require entire colon assessed (3% have synchronous lesion) Plain abdominal X-ray in suspected obstruction Abdominal CT scan (orthogonal, but also virtual)

Symptoms of hyposplenism in Coeliac patients

Howell Jolly bodies, target cells, thrombocytopenia

Aetiology of anal carcinoma

Human papilloma virus type 6, 11 and 16 Anoreceptive intercourse Immunosuppression (HIV, pharmacological, haematological)

MOA of H. pylori

Hypergastrinemia Negative feedback for gastrin is blocked - resulted in uncontrolled excess gastrin and thus hyperacidity Direct mucosal Injury Cytotoxins cause increased production of ammonia Ammonia is toxin to epithelial cells Inflammatory response Mediated by macrophages, neutrophils, T-cell.

Clinical features of acute variceal bleed

Hypotension, haematemesis, malaena Risk factors for chronic liver disease Recent NSAIDS Abdominal sepsis/surgery Pancreatitis/umbilical vein sepsis

IBS Subtypes

IBS - C : IBS with Constipation IBS - D : IBS with Diarrhoea IBS - M : IBS mixed type Patients with both hard & loose stools over period of hours or days IBS - U : IBS unsubtyped Alternating IBS - patients who change subtype over period of weeks and months

Economic impact of IBS

IBS sufferers: miss 3x as many days from work report more often that they are too sick to work visit a physician more often Annual Expenditure: £45.6m GP consultations: £13.1m Prescribed medications: £12.5m Hospital OPD visits: £16.6m In-patient admissions: £3.4m

Hindgut blood supply

IMA

Hindgut drainage

IMV

What is the most common identifiable risk factor for HCV?

IV drug use

Investigations in autoimmune hepatitis.

IgG, anti-nuclear factor, antismooth muscle antibody

What is the core antibody used as indicator of acute Hep B infection?

IgM

Investigations in primary biliary cirrhosis.

IgM, antimitochondrial antibody

Treatment of anal sepsis

Incision and drainage

Indications for CT colonography

Incomplete colonoscopy Patient refusal for colonoscopy Fragile patients Single step staging of patients Clinician referral preference

Disadvantages of laparoscopic vs. open cholecystectomy

Increased risk of bile duct injury

Causes of abdominal inflammation

Infective Chemical Ischaemia/infarction Physical-thermal, radiation, trauma Immune

Manifestations of mucosal damage

Inflammation • Apoptosis or necrosis • Erosion may progress to ulceration • Changes in cell kinetics - Hypoplasia may progress to atrophy - Hyperplasia • Changes in cell appearances - "Reactive / regenerative" atypia - Metaplasia - Dysplasia • Functional derangements e.g. enzyme loss

Investigations for acute pancreatitis

Initial: Pancreatic enzymes (Amylase, Lipase) • Liver function tests • Ultrasound of gallbladder and biliary tree 2nd line: Fasting plasma lipids • Fasting plasma calcium (after acute episode) • Viral antibody titres • Autoantibody / IgG4 titres • MRCP / CT scan of pancreas 3rd line: Repeat GB ultrasound • Endoscopic ultrasound • ERCP (bile for crystals) • Sphincter of Oddi manometry

Factors that initiate portal hypertension

Initiated by increased intra-hepatic vascular resistance Later= increased portal inflow Mechanical factors (60-70%)= Architectural changes, fibrosis, vascular occlusion Dynamic factors (30-40%)= endothelial dysfunction, increased vascular tone

Treatment for gastric variceal bleeding

Injection of tissue adhesives ('glue') Injection of thrombin Band ligation Hemospray Sengstaken-Blakemore tube TIPPS Surgical

Treatment for Hep C cirrhosis.

Interferon + ribavirin

Treatment of HCV

Interferon used initially in nonA-nonB patients Initial trials with standard interferon at various doses with various induction regimens tried Pegylated interferon Pegylated interferon and ribavirin - 60-70%

Treatment for Hep B cirrhosis.

Interferon, lamivudine

Antiviral treatment for chronic HBV

Interferon-alpha (pegylated IFN) L -nucleotide analogues Lamivudine Telbivudine Emtricitabine (FTC) Cyclopentone Adefovir Tenofovir Entecavir

Classification of haemorrhoids

Internal- located above dentate line, covered by columnar/transitional epithelium, 1st, 2nd, 3rd degree External- located below dentate line covered by squamous epithelium Mixed

How does PTC work?

Intravenous sedation+ local anaesthetic • Fine needle inserted through skin into liver • Contrast injected into duct • Guidewire can then be inserted through needle to proceed to drainage/stent

Diagnosis of colorectal cancer

Investigation of symptommatic individuals- lower GI endoscopy, contrast radiography, emergency operation Surveillance- HNPCC, FAP, IBD, prior cancer Population FOBT screening

Facial signs of cirrhosis

Jaundice Xanthelasma Paper dollar skin Rhinophyma Seborrheic dermatitis Parotid swelling

Clinical features of Hep A

Jaundice- >14y/o most common Fulminant hepatitis Cholestatic hepatitis NO CHRONIC SEQUELAE

What can hiatus hernia contribute to?

LOS tone severity of reflux

Specific treatment for hepatic encephalopathy

Lactulose 1st line Cathartic (reduces colonic bacterial load), acidifies gut lumen and inhibits ammoniagenic bacteria Oral, NG, enema (aim for 2-4 BO/24h) PEG lavage solutions via NG in severe HE Low protein diet not recommended Rifaximin 400mg tds PO (gut sterilisation) is 2nd line Secondary prophylaxis - prevents recurrence, ↑ QoL Primary prophylaxis? Assess for transplant

What is the difference between laxatives and Prucalopride?

Laxatives: acts in gut lumen Prucalopride: acts in gut wall after systemic absorption

Ligaments of the liver

Left triangular ligament Coronary ligament Falciform ligament Round ligament

Diagnosis of anal cancer

Lesion biopsy

Features of GORD reflux with low LOSP

Less common (20%) Nocturnal reflux Often large hiatus hernia More severe oesophagitis Barrett's

Treatment of oesophagitis

Lifestyle Mechanical Antacids PPI Prokinetics Strictures- dilatation, long term PPI ?Barrett's

Treatment of GORD

Lifestyle measures (smoking, alcohol, diet, weight reduction) Mechanical (posture, clothing, elevate bed-head) Antacid/alginate Acid suppression (PPI, H2RA) Prokinetics Surgical (or endoscopic?) antireflux procedure - Fundoplication

Indications for liver biopsies

Liver and biliary disorders e.g. - Alcoholic liver disease - Non-alcoholic steatohepatitis (NASH) - Autoimmune hepatitis - Viral hepatitis (assessment of disease activity) - Primary sclerosing cholangitis - Primary biliary cirrhosis - Assessment of fibrosis (cirrhosis) and steatosis (fatty liver) - Metabolic disorders e.g. haemochromatosis - Drug related injury Transplantation pathology - Examination of resected liver - Assessment of liver disease in donor organ - Diagnosis and monitoring of organ rejection Neoplasia - Primary liver tumours less common than metastases • Hepatocellular carcinoma (HCC) • Intrahepatic and hilar cholangiocarcinomas - Where surgical resection is being considered, biopsies are often discouraged • Iatrogenic spread of tumour along biopsy tracks - Metastases of unknown primary • Histological diagnosis may be key to selecting the most appropriate chemotherapy - Biopsies to assess background liver prior to surgery • Ability of remaining liver tissue to regenerate

Microscopic picture of cirrhosis

Loss of hepatocyte microvilli Activated Stellate Cells Deposition of scar matrix Loss of fenestrae Kuppfer cell activation

Features of oesophageal adenocarcinoma

Lower third oesophagus Younger Reflux (Barrett's) Obesity More common Increasing

Hindgut sympathetic nerve supply

Lumbar splanchnic (L1/L2)

Types of mutations in DNA mismatch repair in HNPCC families

MSH2 MLH1 MSH6 PMS2 **All of the above= DNA mismatch repair gene**

What marks the transition between foregut and midgut?

Major duodenal papilla

IBS Behavioural therapy

Meditation Hypnotherapy Relaxation Therapy Cognitive therapy- psychological flexibility/acceptance Biofeedback

What is the difference between a plastic and metallic stent?

Metallic stent: • Last longer • More expensive • Makes subsequent surgery difficult

Management of severe attack of UC

Methylprednisolone IV or hydrocortisone IV IV fluids, electrolytes, transfusion if needed Heparin thromboprophylaxis Abdominal Xray, stool for culture/CDT assay Liaise with surgical colleagues Monitor stool frequency, pulse, temp Flexible sigmoidoscopy within 24hrs with urgent histology

Examples of 5-HT receptor agents

Metoclopramide Cisapride Tegaserod Prucalopride

Features of oesophageal squamous cell carcinoma

Mid/upper oesophagus Older Smoking Alcohol Less common Declining

Side effects of Azathioprine

Minor toxicity i.e. nausea, fever, rash, malaise Pancreatitis Bone marrow depression Allergic reactions Hepatitis **TPMT testing is routine clinical practice**

Features of GORD reflux with TLOSRs

More common Daytime reflux Small or no HH Often no oesophagitis

Define acute severe colitis

More than six stools daily with blood, with evidence of systematic disturbance i.e. anemia, fever, tachycardia, ESR>30, Albumin <30 MEDICAL EMERGENCY

Treatment of chronic pancreatitis

Multidisciplinary approach • Analgesia - specialist pain team • Identification of aetiology • Alcohol counselling • Dietician - nutritional supplements • GI physician • Surgeon

Pathogenesis of liver fibrosis

Multifactorial: nutrition, direct toxicity (i.e. alcohol), immunological (i.e. viral hep C), genetic predisposition

Clinical features of ZES

Multiple ulcers often unusual sites Poor response to standard therapy Complications are common - GI bleed from peptic ulcers Diarrhoea can be the presenting feature

What is Infliximab?

Murine chimeric monoclonal Antibody against TNFa Licensed for: Crohn's, UC **Most effective when combine with Azathioprine**

Examination signs specific to acute abdominal pain

Murphy's sign • Rovsing's sign • Grey-Turner's sign • Cullen's sign

What are the two plexi of the GI tract?

Myenteric (Auerbach's) plexus Submucosal (Meissner's) plexus

2 approaches to cirrhotic ascites

Na restriction and diuretics No added salt diet (90mmol/L) Use combination of spironolactone and furosemide (100:40 ratio) Slow Does not affect survival Large volume paracentesis (LVP) >5 L Fast High rate of recurrence Requires albumin infusion to prevent post paracentesis circulatory dysfunction Does not affect survival

Pathophysiology of ascites in cirrhotic pts.

Na/water retention, portal hypertension Always consider portal vein thrombosis, HCC

Classification of large bowel polyps

Neoplastic- adenoma, familial adenomatous polyposis Hamartomatous- juvenile polyposis, Peutz-Jeghers syndrome, Cronkhite-Canada syndrome, Cowden's disease Inflammatory- benign lymphoid polyp, pseudo-polyp, benign lymphoid poyposis, pseudo-polyposis (UC) Unclassified- metaplastic/hyperplastic, lipoma, neurofibroma, multiple metaplastic polyps, MAP

Treatment for achalasia

Nifedipine Botulinum toxin Pneumatic dilatation Surgical myotomy

Management of diverticulitis

Nil orally IV fluids and antibiotics i.e. metronidazole/cefuroxime repeat examination to ensure resolution

How is IBS diagnosed?

No diagnostic test Absence of biological / physiological markers Exclude other medical conditions DIAGNOSIS BY EXCLUSION

CTC vs. colonoscopy

No difference in detection rates for cancer/large polyps >10mm. No difference in cancers missed. Patients preferred CTC on average

What is the difference between paracentesis and diuretics for the treatment of ascites in liver cirrhosis?

No difference in readmission, mortality or cause of death Diuretics- greater hospital stay, greater complications, less elimination of ascites

Clinical features of pancreatic carcinoma

Non specific abdominal symptoms • Back pain • Obstructive jaundice • Weight loss

Diagnosis of H. pylori

Non-invasive: Breath test, antibody measurement, stool antigen test Invasive: culture, histology, urease (CLO) test

Most frequent causes of admission with acute abdominal pain

Non-specific acute appendicitis acute cholecystitis small bowel obstruction acute gynaecological acute pancreatitis

Features of inactive phase of HBV

Normal ALT HBV DNA < 2000 IU/ml No histological progression Biopsies may show fibrosis from previous phase

Maintenance treatment in PUD

Not necessary after successful HP eradication Patients who cannot avoid taking NSAIDs or Aspirin may require long term protection.

Investigations for chronic pancreatitis

Nutritional assessment - Clinical - Anthropometry - Biochemistry • Morphology of pancreas - CT scan - MRCP/MRI pancreas - ERCP - Endoscopic ultrasound (EUS) Pancreatic function tests - Endocrine - Exocrine • Direct • Indirect

Emergency presentations of colorectal cancer.

Obstruction Perforation Bleeding Localised pain

Management issues for NSAID-induced ulcer?

Offending drug should be removed NSAIDs should be used at lowest effective doses Co-prescription of a PPI will heal most ulcers Prescription of a COX-2 specific drug will limit gastrointestinal toxicity

How does HP cause ulcers?

Oral transmission. Stomach colonisation (NOT duodenum) Lives next to epithelium ; prefers the antrum if H+ secretion very high; it is protected by stomach mucus and its ability to produce urea to buffer acidic pH HP provokes an inflammatory response releasing cytotoxins Vacuolating cytotoxin (vacA), cytotoxin-associated gene (cagA), adhesins, LPS, urease etc Antral somatostatin is depleted and gastrin release by G-cells Hyperacidity occurs with mucosal damage Duodenum develops gastric like tissue (metaplasia) with further colonisation and hyperacidity.

Severe acute pancreatitis

Organ failure and/or local complication - Expression of development of necrosis

Features of somatic abdominal pain

Originates in the parietal peritoneum • T5 to L2 dermatomes • Diaphragm C3-5 and lower six intercostal nerves • Mechanical, thermal or chemical stimulation • Sharp constant pain • Irritation of parietal peritoneum leads to guarding

Secondary prophylaxis for acute variceal bleed.

Oseophageal bleed- After day 5 with VBL + NSBB or NSBB/VBL alone Gastric bleed- After day 5 with cyanoacrylate injection. Consider NSBB or thrombin. TIPSS is an option if large/multiple varices **goal is to decrease portal pressure**

What are some drugs that are important to ask about in GI?

PPIs NSAIDs IBD prescriptions

What to offer at the end of GI exam.

PR exam, external genitalia, external hernia orifices (esp. if surgical exam

Clinical features of anal cancer

Pain, bleeding, itch or ulcer

Types of pancreatic tumours

Pancreatic ducts - 80% ductal pancreatic carcinoma Pancreatic acini Endocrine cells Connective tissue Metastases

Pathogenesis of Crohn's disease

Paneth cells Cigarette smoke NOD2 frameshift mutation Autophagy Dysbiosis

Types of rectal prolapse

Partial (mucosa only)- similar to prolapsing haemorrhoids Complete (entire rectal wall)

Define diuretic intractable ascites.

Patients who cannot tolerate diuretics because of the development of complications

Prognosis of pancreatic carcinoma

Patients with peri-ampullary cancer have a poor prognosis (overall median survival =5mths) • Resection can extend this to 14-18mths • Almost all patients develop recurrent or metastatic disease

What are the differential diagnoses for biliary disease?

Peptic ulcer disease GORD acute pancreatitis acute appendicitis renal pathology- renal/ureteric colic, pyelonephritis IBS

Types of liver biopsies

Percutaneous- under radiological guidance Laparoscopic

Indications for emergency surgery in PUD

Perforation Bleeding

Positive findings you may find on DRE

Perianal : Warts Rashes External/prolapsed haemorrhoids Prolapse Skin tags Soiling, blood, mucous Signs of infestation Fistula Warts Rashes External/prolapsed haemorrhoids Prolapse Skin tags Soiling, blood, mucous Signs of infestation Fistula On Digital insertion : Rectal mass Prostate pathology Loaded or empty rectum Thrombosed haemorrhoids Reduced/absent sphincter tone on squeezing On with withdrawal Fresh blood Melena Infestation

What are the sections of the prostate?

Peripheral zone, central zone, transition zone

Clinical features of peptic perforation

Peritonitis, shock sudden severe pain shoulder tip pain Air under the diaphragm (bilateral) 30-50% of cases are due to peptic ulcer mortality remains 6-10% haematemesis melaena both

Jejunum and ileum radiology investigations

Plain films- perforation, obstruction Follow through Small bowel enema- US CT- Crohn's, acute admission, inpatients MRI small bowel- best test for Crohn's, chronic diarrhoea, out patients Capsule Enteroscopy

Treatment for unwell coeliac patients i.e. weight loss, hypoalbuminaemia, dehydration, steatorrheoa

Prednisolone 0.5 mg/kg

Treatment for refractory coeliac disease

Prednisolone 7.5-20 mg • Consider an immuno-modulator (AZA)

How are bleeding oesophageal varices prevented in liver cirrhosis?

Prevention of initial bleed: (primary) Non-selective beta-blocker Variceal band ligation Prevention of rebleeding: (secondary) Band ligation Propranolol

Types of cirrhosis with low incidence of HCC

Primary biliary cirrhosis Autoimmune hepatitis Wilsons

Process of pH monitoring/impedence

Probe placed 5cm above upper LOS Records pH for 23 hours Reflux= <4 Measure time with low pH i.e. erect, supine, eating

Pathophysiology of peptic ulcer

Produced by the imbalance of gastro-mucosal Defense mechanism - mucous, bicarbonate, prostaglandins Secretions - acid and pepsin (enzyme) Hormone (gastrin)

Clinical features of chronic pancreatitis

Progressive • Irreversible • Inflammatory change, necrosis, fibrosis • Loss of exocrine and endocrine elements

Epithelium of the anal canal?

Protective- stratified squamous

Epithelium of the oral cavity, pharynx and oesophagus?

Protective- stratified squamous

How does biliary drainage work?

Provides immediate relief Decrease in jaundice Decrease in discomfort • Establishes track for stenting

How much do emotional factors contribute to IBS?

Psychological factor ~ 80% Previous depressive illness ~ 40% Current psychiatric illness ~ 70%

Features of spontaenous clearance of HBsAg of HBV

Published studies 0.5-0.8% per year Older age and length of "inactivity" predictors Signify better clinical outcomes HBV DNA in liver and can be found in serum in up to 20% HCC still a risk compared with non-infected controls

What type of virus is Hep A?

RNA picornavirus- single serotype worldwide

Treatment options for hepatocellular carcinoma

Radical/ potentially curative: Resection - first line for solitary tumours, good liver function; recurrence rate 70% at 5 years Transplantation - single tumours <5cm or ≤3 nodules ≤3cm (Milan criteria), unsuitable for resection; UCSF? Down-staging? LDLT? Percutaneous ablation - Radiofrequency ablation (RFA); ethanol Palliative: Transarterial chemoembolisation (TACE) - cytotoxic and ischaemic; delays progression; often repeated Sorafenib and other molecular therapies (Childs A, advanced/ progressing); Clinical trials Symptomatic

Treatments for oesophageal cancer

Radiotherapy- curative/palliative Chemo Endoscopic therapy- laser, Argon plasma, stent Surgery

Scores for assessing severity of acute pancreatitis

Ranson's score • Glasgow (Imrie score) • APACHE 2

'Alarm' symptoms in IBS (markers of organic disease)

Rectal bleeding Documented weight loss or Fever Persistent diarrhoea or Vomiting Constant and recent abdominal distension Anaemia &/or GIH New onset in patients >50 years Family history of bowel cancer, IBD Frequent Nocturnal symptoms Absence of psychological distress Urinary sediment - haematuria

Symptoms of UC

Rectal bleeding, diarrhea with blood and mucus Can develop: pancolitis left-sided colitis procto-sigmoiditis (most common)

ROME IV Criteria for the diagnosis of IBS

Recurrent abdominal pain at least 3 days/month In the last 3 months associated with 2 or more : 1. Improvement with defecation 2. Onset associated with a change in stool frequency 3. Onset associated with a change in stool formation * Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis.

Truncal signs of cirrhosis

Reduced body hair Gynaecomastia Spider naevi

Treatment options for refractory ascites

Repeated LVP (+ albumin) TIPSS Liver transplantation Vaptans? ALFApump?

What is the treatment for bleeding oesophageal varices secondary to liver cirrhosis?

Resucitate Endoscopic therapy with band ligation Terlipressin Balloon tamponade TIPSS (transjugular intrahepatic portosystemic stent shunt)

Types of resections for colorectal cancer

Right hemicolectomy Extended right hemicolectomy Left hemicolectomy Anterior resection

COX-2 specific drugs

Rofecoxib (Vioxx withdrawn) Celecoxib still available.

Midgut blood supply

SMA

Midgut drainage

SMV

LVP for cirrhotic ascites.

Safe and effective treatment for recurrent ascites Informed consent Paracentesis induced circulatory dysfunction ∼100 mL of 20% albumin/3L ascites drained Sterile procedure Leakage through puncture site afterwards- purse-string suture Incidence clinically significant intraabdominal bleeding 0.5%

Infective causes of UC

Salmonella Shigella Campylobacter jajuni Enteropathogenic E.coli C. diff- psuedomembranous colitis

Endoscopic appearances of coeliac disease

Scalloping of D2 mucosa Flat villi under water

Epithelium of the stomach?

Secretory- long tubular glands

Treatment for uncontrolled variceal bleeding

Sengstaken-Blakemore tube (balloon tamponade)- 90% effective Self-expandable (Danis) stent- haemostasis through direct compression of varices Transjugular intrahepatic portosystemic shunt (TIPSS)

What are the indications for surgery in Crohn's disease?

Sepsis- fistulae, abscess, perforation Obstruction Failure of Medical Treatment Haemorrhage Growth retardation, haemorrhage, fulminant colitis Cancer

Investigations for ZES

Serum gastrin levels are grossly elevated Secretin stimulation further increases levels Tumour localisation difficult CT EUS and sampling Selective Angiography for bleeding complication

Adjuvant radiotherapy for rectal cancer

Short course pre-op - 25Gy over 5 days in week leading up to surgery Long course - 52 Gy over 3 months 30% reduction in local recurrence rate No overall mortality reduction for any XRT regimen Down-staging inoperable to operable cancers

Non-GI causes of altered bowel habit

Simple constipation Depression- constipation Hypercalcaemia- constipation Thyrotoxicosis/hypothyroidism Neuroendocrine tumours Drugs i.e. opiates, antibiotics Painful anal conditions

Define diffuse oesophageal spasm

Simultaneous contractions + intermittent normal peristalsis Associated findings= repetitive contractions >3 peaks, prolonged duration of contractions, high amplitude contractions, frequent spontaneous contractions, lower oesophaeal sphincter abnormalities- incomplete relaxation, high residual pressures

How to describe a prostate mass on DRE

Site Size Surface Colour Contour- well-defined/irregular Consistency- soft/firm/hard Tenderness Temperature- hot/inflammed? Transilluminable Fluctuance- fluid-filled cyst? Fixity Fields- lymph glands in area Is the lump: Pulsatile, expansive, reducible?

What are the layers of the anterior abdominal wall?

Skin Subcutaneous fatty tissue (Campers then Scarpas then Investing) External oblique Internal oblique Transversus abdominis Fascia transversalis Extraperitoneal fat Peritoneum

Risk factors for gastric cancer

Smoking HP [in patients with normal/low H+ secretion] - Class 1 carcinogen (WHO) Alcohol FAP syndromes Pernicious anaemia Diet rich in nitrosamines*

How is ascites treated in liver cirrhosis?

Sodium restriction + diuretics ?Paracentesis

Direct antivirals for treatment of HCV

Sofosbuvir- once daily NS5B inhibitor pan genotypic Simeprevir- once daily protease inhibitor genotype 1 (better in 1b) Daclatasvir- NS5A inhibitor pan-genotypic once daily Ledipasvir/Sofosbuvir- single tablet once daily Abbvie- ABT450/RTV/Ombitasvir + Dasabuvir + RBV

What are the 3 components of IBS?

Soma Psyche Circumstance

Prevalence of Hep E

South- East France up to 50% of blood donors IgG positive UK not clear as no good study done (Scotland about 5% of blood donors)- pork sausage 13% of presumed drug-induced liver injury acute HEV Can become chronic in immunosuppressed

Clinical features of hepatic encephalopathy

Spectrum of neuropsychiatric abnormalities in patients with acute or chronic liver dysfunction

Features of H. pylori

Spiral-shaped, gram -ve acidophilic bacterium 0.5 x 3 micron; 4-6 flagella Multiple sheathed flagella Strong urease activity Shape, motility & Enzymatic action allows to penetrate beneath mucosal layer

Pathological features of Barrett's oesophagus

Squamous to metaplastic columnar epithelium Intestinal metaplasia (with goblet cells) High grade dysplasia

Macroscopic types of colorectal cancer

Stenosing, ulcerating, proliferative

Radiology interventions for malignant obstructive jaundice

Stenting by ERCP or percutaneously if inoperable Percutaneous options= • PTC • Biliary drainage catheter • Stent - Plastic - metal

Examination features of acute variceal bleed

Stigmata of chronic liver disease Cardiovascular compromise Hepato-splenomegaly/ascites Hepatic bruits

MOA of Prucalopride

Stimulates motility, induces colonic high amplitude propagating contraction & facilitates transit & propulsion Acts on 5-HT4 receptors located on the nerves in the gut wall to release the neurotransmitter acetylcholine New approach to treat impaired propulsion: Highly selective for its target receptor (5-HT4 ) Targets the muscle layer directly (rapid) in contrast to luminally (slow) acting laxatives

What are the intraperitoneal structures?

Stomach, liver, spleen, 1st part of duodenum, tail of pancreas, transverse colon, sigmoid colon

Structures in the foregut

Stomach, proximal duodenum, liver, pancreas, gallbladder, spleen

UC investigations

Stool culture Sigmoidoscopy/colonoscopy Histology

Treatment of PUD

Stop smoking Avoid aspirin , NSAID's Alcohol in moderation Short term management awaiting HP status: Proton pump inhibitors or H2 blocker omeprazole 20-40mg od OR ranitidine 300mg OD First Line (90% efficacy) Lansoprazole 30mg twice daily (or omeprazole 20 mg BD) Clarithromycin 500mg twice dailyMetronidazole 400mg twice daily all three for 1 week only Second Line (85%-90% efficacy) Lansoprazole 30mg twice daily(or omeprazole 20 mg BD) Clarithromycin 500mg twice dailyAmoxycillin 1g twice daily all three for 1 week only Note: For patients allergic to penicillin, repeat 1st line regimen as 2nd line

What are the consequences of non/under-treated Crohn's?

Strictures Fistula/abscess Surgery Strictures

Management of gastric cancer

Surgery Chemotherapy - for inoperable disease Endoscopic for palliation -APC, Laser, stents

Treatment of rectal prolapse

Surgery Perineum= Delorme's Abdomen= rectopexy

3 broad categories of causes of acute abdominal pain

Surgical Medical Gynaecological

Management of ZES

Surgical resection if tumour localised PPI's high doses Octreotide injections to reduce gastrin levels 5 -y survival 60-75%

Features of visceral pain

Sympathetic branch of the autonomic nervous system • T6-12 and L1-2 through splanchnic nerves • Distention, traction, spasm, ischaemia • Dull poorly localised

Secondary disorders of oesophageal motility

Systemic sclerosis Myasthenia gravis Pseudoachalasia Drugs

Who is offered surgery in oesophageal cancer?

T1-3, N0-1, M0 mainstay of curative treatment consider pre-op chemo

Where does somatic pain come from?

T4-L1 (afferent) Nocioception- peritoneal irritation, chemical, mechanical Localised to anatomy

Side effects of infliximab

TB Serious infections Post-op complications Malignancy Lupus Immunogenicity Allergy

Treatment of type 1 HRS in cirrhotic patients.

Terlipressin with albumin Increases the number of patients with reversal of HRS Adverse events Only 40-50% respond

CT signs of Crohn's disease

Terminal ileum: thickened mucosa, cobblestoning Rosethorn ulcer, 'string' sign

Clinical features of acute Hep C

The more symptomatic the better Icteric illness High ALT more likely to spontaneously clear

Laymens terms for describing prostate

The prostate gland is only found in men. It lies just beneath the bladder. It is normally about the size of a chestnut. The urethra (the tube which passes urine from the bladder) runs through the middle of the prostate. The prostate's main function is to produce fluid which protects and enriches sperm

Pathological features of microscopic (collagenous) colitis

Thickened basement membrane Increased intra-epithelial lymphocytes Increased chronic inflammatory cells in lamina propria

In whom should pH monitoring be performed?

Those with: 1. Classic reflux symptoms and inadequate response to therapy 2. Atypical symptoms i.e. normal endoscopy, GORD, anti-reflux surgery, atypical symptoms, noncardiac chest pain

What are the aims of treating benign PUD?

To alleviate painful symptoms Promote healing To prevent complications To prevent recurrence of ulcer

Aetiology of acute pancreatitis

Trauma •Drugs •Hyperparathyroidism •Hyperlipidaemia •Infection •Periampullary cancer •Hereditary •Vascular disease •Hypothermia •Autoimmune

How should you treat pregnant women with chronic HBV?

Treat high viral load (106-7) mothers in last trimester to prevent transmission to child- tenofovir or lamivudine

Types of colorectal adenomas

Tubular Tubulo-villous Villous

Pathological prognostic factors for colorectal cancer

Tumour type (standard, signet cell, mucus producing, anaplastic) Extent of local spread/peritoneal involvement Histological grading (degree of differentiation) Lymph node involvement Lymphatic invasion on microscopy Vascular invasion on microscopy Pushing vs infiltrating margin Host lymphocytic infiltration

Jaundice radiology investigations

US- are ducts dilated? CT- metastatic disease MRI: MRCP ERCP

RUQ pain?gallstones radiology investigations

US- cheap, safe, accurate; shows liver, biliary tree and gallbladder, also kidneys, pancreas and spleen Cholesterol pigemented gallstones are opaque on US if there is 10-20% enough calcium

Radiological investigations for painless obstructive jaundice?pancreatic carcinoma

US- dilated ducts CT- dilated biliary ducts, pancreatic mass, pancreatic duct dilation

Diagnosis of pancreatic carcinoma

USS CT Staging- CT abdo, chest, laparoscopy Assess co-morbidity/fitness

Clinical presentation of anal carcinoma

Ulcer, warty lesion, pruritis, pain, bleeding

Side effects of methotrexate

Ulcerative stomatitis Leukopenia Nausea Malaise Fatigue Chills and fever Dizziness Decreased resistance to infection

HCC radiology investigations

Ultrasound for screening (no radiation) CT liver MRI liver

Indications for TIPSS treatment.

Uncontrolled or recurrent variceal bleeding Gastric varices Refractory ascites

Prevalence of Hep Ca.

United Kingdom - < 1% HCV antibody positive (genotype 1 60%, geno 2/3 40%) Mediterranean- 1-3% HCV ab positive (genotype 1 85%, geno 2/3 15%) US - 1.7% (genotype 1 80%, geno2/3 20%) North Africa -15% (genotype 4)

Prevention of HRS in cirrhotic patients

Use of antibiotics during acute variceal haemorrhage Use of albumin during SBP Avoid PPIs? No Avoid beta-blockers? Therapeutic 'window' Earlier detection (biomarkers)....earlier interventio n

Clinical features of acute pancreatitis

Variable • Severe abdominal pain radiating to the back • Vomiting • Organ failure - respiratory, renal • Jaundice, cholangitis • Clues: Severity, site, radiation Grey Turner's sign, Cullen's sign, ARDS

Clinical features of diverticular disease

Very common but often asymptommatic Pain, tenderness in LIF, alternating constipation/diarrhoea

Clinical features of gastric outlet obstruction

Vomiting of previously eaten food Dehydration Abdominal distension Visible gastric peristalsis Succussion splash

Clinical features of Crohn's

Watery diarrhoea Abdominal pain Anorexia and weight loss Lethargy Mouth ulcers Missing school Peri-anal abscesses

General signs of cirrhosis

Weight loss jaundice unkempt

Define Globus Pharyngeus

When globus is not associated with pharyngeal pathology i.e. disorder of sensitisation of sensory nerves in pharynx Assoc. with other functional disorders

Pathophysiology of Zollinger-Ellison syndrome

Xs Gastrin - Non-beta cell islet tumour of pancreas (gastrinoma) Gastric acid hyper-secretion causing Peptic ulceration 2/3 are malignant but slow growing 20-60% have co-existing adenomas of parathyroid and pituitary (MEN 1 - Multiple endocrine neoplasia type1) 0.1% of ulcer cases Gastrin hypersecretion causes hyperacidity and ulcers Pancreatic enzymes get inactivated due to low pH and bile salts precipitate causing diarrhoea and steatorrhoea

Define functional bowel disease

a functional gastrointestinal disorder with symptoms attributable to the mid or lower gastrointestinal tract

What is the prostate?

a partly fibromuscular organ which lies in the pelvic cavity in front of the rectum, behind the symphysis pubis and is penetrated by the proximal part of the urethra - broader than long - 4x3x2cm - 8g in youth, 40g at 50

Symptoms of small bowel Crohn's

abdominal pain, diarrhea, fever, steatorrhea, abdominal mass, weight loss

What are the retroperitoneal structures?

abdominal part of oesophagus, 2nd-4th parts of duodenum, most of pancreas, ascending and descending colon, rectum Aorta, IVC, kidneys, ureters, suprarenal glands, autonomic nerves

What are the factors that contribute to IBS aetiology?

abnormal motor function visceral hypersensitivity brain-gut interaction 5-HT mediated visceral hypersensitivity and gut motility Chemical, stress, anxiety, depression, hormones, genetics, meds, trauma, food, infection ***Multifactorial***

US signs of gallstones

acoustic shadow

What is the role of 5-HT?

act as transducers detecting: 1. changes in chemical environment intestinal lumen *Release serotonin 2. Serotonin receptors on sensory nerves Initiate peristalsis 3. *Enterocytes SERT (transporter) Inactivate response

What type of disease does Hep A cause?

acute disease + asymptommatic infection No chronic infection- protective antibodies develop in response to infection- confers lifelong immunity

Types of oesophageal cancer

adenocarcinoma, squamous cell carcinoma

What is impedence tested for?

allows assessment of non-acid reflux, also for studies on acid suppressing recommendations

Alarm symptoms of peptic ulcer disease

anaemia hematemesis melaena vomiting anorexia/weight loss pain radiation early satiety nocturnal pain perforation (severe pain, peritonism)

What is reflux prevented by?

anatomy tone of LOS secondary peristalsis

Treatment for Budd-Chiari syndrome cirrhosis.

anticoagulation, decompression of venous system

CT sign of appendicitis

appendicolith

Risks of balloon tamponade for variceal rupture

aspiration, oesophageal perforation, malposition

Genetic inheritance of FAP

autosomal dominant- penetrance= 100% inactivating mutations of APC gene (5q21)

Hep A incubation period

avg 30 days (15-50)

Hep E incubation period

avg 40 days (15-60)

Define nutcracker oesophagus

avg peristaltic pressure > 2 SD above well documented normal range in distal oesophagus (>180mmHg) Assoc= hypertonic LOS, peristaltic waves of long duration

Secondary causes of peritonitis

blood, bile, enteric contents

Foregut blood supply

celiac trunk

Clinical features of nutcracker oesophagus

chest pain, dysphagia

ERCP outcomes

cholangiography successful in 90% CBD cleared in 80%- avg= 2 procedures Complications= 5-10% Mortality= 1-2%

Things to look for in the hands in GI

clubbing, nail signs, erythema

XR sign of sigmoid volulus

coffee bean sign

Features of intermittent acute cholecystitis pain.

colicky pain - obstruction/irritation smooth muscle visceral sensation

What can Hep E be a cause of?

decompensation of chronic liver disease

Structures in the hindgut

descending colon, sigmoid colon, rectum, anus

Structures in the midgut

distal duodenum, jejunum, ileum, ascending colon, transverse colon

How do you decide on which therapeutic options to pursue in a patient with malignant obstructive jaundice?

do a CT/MRI

Foregut sympathetic nerve supply

dominant: greater splanchnic (T6-T9)

Midgut sympathetic nerve supply

dominant: lesser (T10/11) and least T12) splanchnic

What is the mesentery?

double layer of peritoneum anchoring an organ to the posterior abdominal wall

Management of pericolic abscess

downstaging with antibiotics +/- percutaneous drainage by U/S

Clinical features of eosinophilic oesophagitis

dysphagia Younger age, M>F, prevalence 50/100,000 History of atopy (asthma, hay fever)

Clinical features of oesophageal cancer

dysphagia weight loss chest pain anaemia short, progressive hx suspicious

Clinical features of achalasia

dysphagia, weight loss, chest pain **can progress to oesophageal dilatation and respiratory complications**

Investigations for oesophageal cancer

endoscopy, BA swallow, CT, EUS< laparoscopy

Invesigations for oesophagus

endoscopy- oesophagitis barium swallow- hiatus hernia oesophageal manometry CT PET Endoscopic US

Investigations for Nutcracker oesophagus

endoscopy/barium swallow, manometry

Investigations for diffuse oesophageal spasm

endoscopy/barium swallow, manometry

What secretes 5-HT?

enterochromaffin cells

Clinical features of CBD stones

epigastric pain nausea/vomiting intermittent jaundice

What are the layers of the gut mucosa?

epithelium, lamina propria, muscularis mucosae

What is a polyp?

excrescence of colonic mucosa Does not formally indicate nature of the lesion

What ligament provides the separation between right and left ANATOMICAL liver lobes?

falciform ligament

What is the strongest known risk factor in the development of Crohn's disease?

fam hx

What type of virus is Hep C?

flaviviridae enveloped single-stranded RNA virus Heterogeneous genetically 6 major genotypes Chimpanzee only possible model for animal studies

What is the omentum?

fold of peritoneum connecting stomach to other abdominal organs

Define eosinophilic oesophagitis

food bolus obstruction, dysphagia

Indications for elective surgery in PUD

gastric outflow obstruction Recurrent ulcer following surgery

Prophylaxis for varices

grade 2/3 varices or any with red signs) with non-cardioselective beta blockers (carvedilol) or variceal band ligation

Symptoms of colon Crohn's disease.

haematochezia, diarrhea, fever, weight loss

Side effects of ribavirin for treatment of HCV

haemolytic anaemia, usual drop about 2g/dl

What predicts clinical deterioration in cirrhosis?

hepatic venous pressure gradient (HVPG) If HVPG <10, then only 15% chance of decompensation over 8 years

Direction of Transversus abdominis fibres

horizontal

Causes of globus

hysteri- depression/OCD

What is late death in acute pancreatitis due to?

infected pancreatic necrosis

Types of colic pain

intestinal- small bowel, colon ureteric uterine

Differentials for hepatic encephalopathy

intracranial lesions, infection, ETOH withdrawal, post-ictal

What is a risk factor for local recurrence?

involvement of a surgical resection margin by tumour

What is a risk factor for peritoneal (trans-coelomic) metastasis?

involvement of peritoneal surface

Management of gastric outlet obstruction

iv fluids correction of acidosis nasogastric suction endoscopy Surgical (pyloroplasty/Bilroth Op) or endoscopic management (Stents)

Aetiology of diverticular disease

lack of fibre in diet

Prophylaxis of inactive carriers with HBV.

lamivudine before significant immunosuppression and if rituximab then for anti-HBc positive, HBsAg negative

Management of diverticular perforation

laparotomy, peritoneal toilet, Hartman's resection

What is the greater sac?

larger subdivision of the peritoneal cavity

Treatment of fistula in ano

laying open or seton suture

What is the ultimate treatment for cirrhotic ascites?

liver transplant

What are sinister symptoms of PUD pointing towards malignancy?

loss of appetite/weight loss vomiting (?gastric outlet obstruction) Pain radiation = pancreatic pathology

Elective surgery for colorectal cancer

low rectal cancer require mechanical bowel preparation Segmental resection (eg R-hemicolectomy, ant. resection etc) Restorative rectal excision +/- colonic pouch Transanal excision of rectal cancer Colonoscopic polypectomy

Direction of external oblique fibres

medial and downwards

Direction of internal oblique fibres

medial and upwards

Prognosis of Type 2 HRS

median survival of 6 months

Aetiology of anal cancer

most commonly squamous carcinoma sometimes arise from anal warts of AIN, especially in HIV positive individuals

Causes of chest pain

motility disorders reflux irritable oesophagus

What are the layers of the gut tube?

mucosa, submucosa, muscularis propria, adventitia

What is early death in acute pancreatitis due to?

multi organ system failure

Side effects of interferon for treatment of HCV

myalgia, fatigue injection site reaction dry skin, dermatitis depression neutropenia, thrombocytopenia autoimmunity

What is a Schatzki ring?

narrowing of lower oesophagus that can cause dysphagia

Define tertiary waves

non-peristaltic, non-propulsive waves occurring spontaneously

Emergency surgery for colorectal cancer

obstructed, perforated- unprepared bowel Segmental excision and on-table colonic lavage Colectomy and ileorectal anastomosis Hartmann's procedure

Causes of odynophagia

oesophagitis infection motility disorders

What patients with Barrett's have a greater risk of developing adenocarcinoma?

older men

Define heartburn

pain behind the breast bone spreading upwards- 'pyrosis' - may be acid in mouth - meal related - postural

Define odynophagia

painful swallowing

Hindgut parasympathetic nerve supply

pelvic splanchnic (S2-S4)

Treatment for Wilsons' cirrhosis.

penicillamine, triantine

What is the ligament?

peritoneal fold connecting organ to organ or to posterior abdominal wall

Features of constant acute cholecystitis pain.

peritoneal inflammation cholecystitis vs. biliary colic body wall localisation- localised/diffuse pain exacerbated on movement/coughing/breathing

Epidemiology of H. pylori infection

prevalence correlates best with socio-economic status rather than race Probability of being infected is greater (USA) for older persons (>50 years = >50%) minorities (African Americans 40-50%) Immigrants from developing countries (Latino > 60%, Eastern Europeans > 50%). The infection is less common in more young and affluents Caucasians ( < 40 years = 20%).

What is THE test of liver function?

prothrombin time

Pathophysiology of diverticular disease

pulsion diverticulae due to spasm diverticulae predominate in sigmoid colon

Examination features of acute cholecystitis

pyrexia/tachycardia RUQ peritonism- tenderness +/- guarding, positive Murphy's sign Palpable tender gallbladder

Treatment for Nutcracker oesophagus

reassurance nitrates CCB

Treatment for diffuse oesophageal spasm

reassure nitrates CCBs pH

Advantages of colectomy in UC

reduced mortality cures colitis removes unpredictability and risk of cancer gives control, off medication

Define waterbrash

reflex hypersalivation secondary to gastro-oesophageal reflux

Clinical features of diffuse oesophageal spasm

retrosternal pain, dysphagia may be asymptommatic

Define chest pain (GI)

retrosternal pain, episodic or persistent can occur with or without swallowing

Acute cholecystitis referred pain

right scapula

4 lobes of the liver

right, left, caudate, quadrate

Indications for intervention in Barrett's

severe dysplasia carcinoma in situ over cancer w/o mets

Diaphragm referred pain

shoulder

What is the lesser sac?

smaller subdivision of the peritoneal cavity

Define dysphagia

something sticking in throat or chest, either from localised or general disease **symptom with high predictive value for serious disease**

Things to look for on the skin in GI

spider naevi, telangiectasia, icteric rash, gynaecomastia/hair loss

Define primary peristaltic wave

starts in pharynx at onset of swallowing

Define secondary peristaltic wave

starts locally in response to direct stimulation i.e. after reflux episode

Treatment for AICAH cirrhosis.

steriods and azathioprine

Types of ectopic varices

stomal, rectal

What are gallstones?

stonelike deposits commonly seen in gall-bladder; cause pain when obstructing cystic duct, may obstruct biliary system or pancreatic duct as well

Normal epithelium of oesophagus

stratified squamous inner circular layer, outer longitudinal layer Upper 1/3 striated muscle, lower 2/3 smooth muscle Well developed elastic serosa

Radiological signs of acute pancreatitis

swelling, surrounding fluid, calcification in duct, dilated duct best test= CT

What is the rectus sheath?

the aponeurosis of transversus abdominis, internal and external oblique- completely encloses the proximal 3/4 of rectus abdominis and covers the anterior 1/4

Define GORD

the occurrence of symptoms, or mucosal injury, or both, as a result of reflux of gastric content into the oesophagus

What is the arcuate line?

the point midway between pubic symphysis and umbilicus; at which all the aponeuroses move anterior to rectus muscle

What is the peritoneal cavity?

the potential space between the parietal and visceral peritoneum

MRI signs of Crohn's disease

thickening of wall, dilation upstream, skip lesions

What does the prostate secrete?

thin, milky fluid that makes up about 30% of the semen volume

Examination features of Crohn's

thin, pale fever weight loss nutritional deficiency abdo mass peri-anal disease joint, eye, skin problems

CT signs of ischaemic colitis

thumbprinting sign

Spleen referred pain

to the left

Liver referred pain

to the right

Foregut drainage

tributaries of the portal vein

Define peptic ulcer

ulcer= penetrates the muscularis mucosae, can be acute or chronic (fibrosis) + peptic= in oesophagus or stomach or duodenum

Treatment for CF cirrhosis.

ursodeoxycholic acid

Treatment for primary biliary cirrhosis.

ursodeoxycholic acid

Management of diverticular haemorrhage

usually settle spontaneously

Foregut parasympathetic nerve supply

vagus

Midgut parasympathetic nerve supply

vagus

Treatment for haemochromatosis cirrhosis.

venesection

Examination signs of oesophageal disease

weight loss anaemia lymphadenopathy dental erosions systemic disease

When is the common bile duct 'dilated'?

when it is >6mm in diameter Can be obstructed by stone or tumour at lower end Sometimes dilated in elderly and in post-cholecystectomy patients

CT signs of ascaris

worm-like structures on CT

Prognosis for gastric variceal bleeding

worse outcome, mortality= 50%

Treatment for dermatitis herpetiformis associated with Coaliac disease

• 1) GFD = 6-12/12 • 2) Dapsone Patients on GFD are at risk of osteoporosis therefore: **All patients with new diagnosis of coeliac disease should have a base line DEXA scan and calcium and vitamin D levels checked**

Demographics of acute abdominal pain

• 50% surgical admissions are emergencies • 50% surgical admissions are for abdominal pain

Efficacy of gluten free diet

• 70% respond symptomatically • 30% refractory non-compliant inadvertent intake another diagnosis

What is gluten?

• A protein in the flour that form the structure of the dough • Specific peptide fraction of protein that is found in wheat ,rye & barley

Frequency of aetiological sources of cirrhosis

• Alcohol 50-60% • Viral Hepatitis 10-20% • Primary Biliary Cirrhosis 5-10% • Cryptogenic 5-10% • Autoimmune Hepatitis 5% • Haemochromatosis 1-5%

Treatment of acute pancreatitis

• Analgesia • Fluid resuscitation • ? Antibiotics Surgery: Doubt in diagnosis • Early cholecystectomy • ERCP - Acute cholangitis - Jaundice - Dilated bile duct on USS • Necrosectomy - MIRP - Open • Bleeding • Pancreatic abscess • Pancreatic pseudocyst

Differential diagnoses for coeliac disease

• Autoimmune enteropathy • Bacterial overgrowth/ infective gastroenteritis • Irritable bowel syndrome • Collagenous Sprue • Crohns disease • HIV enteropathy • Lactulose intolerance • Ischaemic enteritis

Colon and rectum radiology investigations

• Barium enema- i.e. polyp, caecal carcinoma • WS enema • CT • MRI- rectal carcinoma and liver mets • Colonoscopy • Virtual colonoscopy- CT scan, computer reformation, non-invasive, patient friendly

Why does gluten-free diet treatment for coeliac disease fail?

• Check diagnosis correct • Consider second diagnosis • pancreatic insufficiency • Check Compliance • inadvertent/intentional • Refractory sprue • REPEAT DUODENAL BIOPSY

Examination features of cirrhosis

• Clubbing • Leukonychia • Palmer erythema • Dupytrens contracture • Hepatic flap, encephalopathy • Hyperdynamic circulation • Jaundice • Spider naevi • Hepatosplenomegaly • Ascites

Clinical categories of coeliacs.

• Coeliac disease • Undiagnosed / silent coeliac disease ( Biopsy positive, no clinical symptoms) • Latent coeliac disease ( Serology positive, Biopsy negative with no clinical symptoms)

Diseases that are associated with Coeliac disease.

• Dermatitis herpetiformis (due to IgA deposition at BM) • IgA deficiency • SBBO • Hyposplenism • Autoimmune conditions i.e. Thyroid disease, Type 1 diabetes, Addison's, Sjogrens syndrome

Pathogenic classification of liver cirrhosis

• Drugs and toxins; Alcohol, methotrexate • Infective; Hepatitis viruses, schistosomiasis • Biliary; primary (PBC) or secondary biliary cirrhosis, primary sclerosing cholangitis (PSC) • Autoimmune Hepatitis • Metabolic; non-alcoholic steatohepatitis (NASH), Haemochromatosis, Wilsons disease, Alpha-1- antitrypsin deficiency • Vascular; Budd-Chiari syndrome, veno-occlusive disease • Cryptogenic

Indications for barium swallow.

• Dysphagia • Pain on swallowing • Assessment of perforation (ws)

Investigation findings of cirrhosis

• FBC; anaemia (macrocytic), thrombocytopaenia • Clotting; prolonged prothrombin time • U&E; hyponatraemia, low urea, rising creatinine very ominous • LFT; hyperbilirubinaemia (>100umol/L), transaminases increased, increased Alkaline phosphatase and GGTP, albumen low • USS may show shrunken liver, ascites or splenomegaly • Endoscopy may show varices or PHG

Treatment of coeliac disease

• Gluten-free diet • Avoidance of wheat, rye and barley • Oats (probably OK) • Dietician • Codex Alimentarius • Coeliac societies handbook

How can serology be used to monitor coeliac patients?

• IgA gliadin and TTG normalise on a strict GFD after 3-6/12 • Must have pre-treatment levels • IgG gliadin can be used but takes longer to normalise • IgA endomyseal is costly and more difficult to quantify

Surgical causes of acute abdominal pain

• Inflammation • Obstruction • Ischaemia • Perforation

Pitfalls in gluten free diet

• Insufficient advice (or effort) • Malted cereals + Cornflakes • Beer contamination • Cooking sauces • Oat contamination

Clinical features of coeliac disease.

• Lethargy "Tired all the time" • Anaemia (Fe, folate, B12 and mixed) • Abdominal pain • Non-specific abdominal symptoms • Diarrhoea • Weight loss • Osteoporosis • Sub-fertility

What are the current problems with liver transplants?

• Limited donors • Increasing need • Long term complications

What are some alternative solutions to liver transplantation?

• Living related transplantation • Non-heart beating donors • Better immunosuppression (use/agents) • Liver dialysis

Treatment of hyposplenism in Coeliac patients

• Meningococcal, Pneumococcal + HIB vaccinations • Prophylactic antibiotics ***ALL patients with new diagnosis of coeliac disease require annual flu vaccines and also pneumococcal vaccine***

Common indications for endoscopic biopsies

• Oesophagus - Gastro-oesophageal reflux disease (GORD) - Barrett's oesophagus- Diagnosis, Surveillance for dysplasia - Neoplasia- Adenocarcinoma, Squamous cell carcinoma - Infections e.g. Candida, HSV Gastritis- H.pylori (antrum), Chemical (antrum), autoimmune/atrophic (body) Neoplasia- adenocarcinoma, GIST, lymphoma Duodenum- Coeliac disease, iron-deficiency anaemia, peptic duodenitis Neoplasia in the colon- adenomas and adenocarcinomas, NHS bowel cancer programme IBD- diagnosis, monitoring, surveillance for dysplasia Colitis- infective, ischaemic, microscopic

How is coeliac disease diagnosed?

• Serology +D2 Biopsies (≥4 biopsies with jumbo forceps)- IgG1 subgroup more specific than IgG, combine both IgA and IgG1 EMA/tTG testing • Recent studies suggest increase yield with additional bx from D1 • HLA typing also useful • Repeat biopsies on treatment/ Repeat challenge (>10g per day, 2/52) • ESPGAN guidelines

What is the diagnostic utility from endoscopic biopsies dependent on?

• Skill and experience of endoscopist • Size of biopsies • Site of biopsy or biopsies • Number of biopsies • Experience of pathologist

Types of abdominal pain

• Somatic (Parietal) • Visceral

Indications for oesophageal CT scan.

• Tumour staging • Assessment of postsurgical patients

Liver and biliary tree radiology investigations.

• Ultrasound • CT • ERCP - Endoscopic retrograde cholangiopancreatography • MRCP - Magnetic resonance cholangiopancreatography • PTC - Percutaneous transhepatic cholangiography EUS Endoscopic Ultrasound Angiography or CTA CT-PET

Indications for water soluble (iodine) swallow

• Used when risk of perforation or aspiration • Non-ionic contrast

Clinical features of cirrhosis

• Variable • Incidental finding at PM (2%) • Asymptomatic abnormal liver function tests • Systemic cutaneous signs • Liver failure e.g. jaundice, encephalopathy, ascites or bacterial peritonitis • Portal hypertension; Bleeding varices • Hepatocellular carcinoma

Pathological features of 'the coeliac lesion'

• Villus atrophy • Crypt hyperplasia • Loss of enterocyte height • Lamina propria infiltration • Increased intra-epithelial lymphocytes • Increased mitotic activity