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