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does oesophageal carcinoma present with clubbing?
what are the symptoms of oesophageal carcinoma?
- PROGRESSIVE, unrelenting dysphagia
- weight loss
- cervical lymphadenopathy
- retrosternal chest pain
where does oesophageal carcinoma commonly metastasise to?
- regional lymph nodes in 50% at diagnosis
- gastric glands
- then liver
what is the Dukes classification for colorectal cancer staging?
- A: penetrated muscular mucosa may have gone into submit or musc propria but confined to bowel wall & LN-ve
- B: extension through the bowel wall into mesorectal/pericolic fat/ LN-ve
- C: involvement of regional LN (C2 - apical LN)
- D: distant mets eg liver or lung, bone peritoneal cavity
when would children get peptic oesophagitis?
hiatus hernia complication
what is cardiomyotomy (Heller's procedure) and what is it used for?
- muscles of the cardia (LOS) are cut to allow food and lqd to pass to stomach
- surgical Rx of achalasia as LOS cant relax properly
how would you check myotomy has worked and what are the risks?
- Ba swallow to check for leak post surgery
- Risk: perforation and stomach acids easily reflux up so may also need partial fundoplication to reduce post op acid reflux!
in which sites are incidence of gastric ca rising and which falling in the West?
- rising: gastro oes junction
- falling: distal and body
where is the most common site for gastric cancer?
antrum (nb anatomy: fundus - body - antrum - pyloric canal - pylorus)
what is atrophic gastritis? and cause?
- chronic inflam of stomach muscosa leading to LOSS OF GASTRIC GLANDULAR cells. they are replaced by intestinal and fibrous tissue
- cause: persistent infection with H pylori or autoimmune
what are the consequences of atrophic gastritis?
stomach doesn't have glands anymore so reduced secretion of HCl acid, pepsin, intrinsic factor leading to DIGESTIVE PROBLEMS, vitamin B12 deficiney MEGALOBLASTIC ANAEMIA
which cells release gastric acid?
which cells release gastrin?
G cells in stomach, duodenum, pancreas
which cells release intrinsic factor?
what type of patients are predisposed to mesenteric ischaemia?
- AF - arterial embolus
- previous TIA
which part of bowel is most commonly involved in mesenteric ischaemia? and why?
splenic flexure as it is the site of watershed between superior and inferior mesenteric arteries
describe the arterial supply of the bowel in 3 categories?
- foregut: coeliac axis, also but to jéjunum
- midgut: lower duod to 2/3 of TC: superior mesenteric artery
- hindgut: distal third TC to rectum: inferior mesenteric artery
in carcinoma of caecum, if bleeding and obstruction were to occur how would they be different to sigmoid colon cancer?
- bleeding: occult, dark colour
- small bowel obstruction
what is the change in bowel habit in caecal cancer?
change in bowel habit: inc frequency with caecal
pyloric stenosis usually occurs in infants, but what can cause it to occur in adults?
chronic peptic ulceration and a narrowed pylorus forms.
what are the symptoms of adult pyloric stenosis?
vomiting large amounts of food a few hours after meals
what is the treatment of adult pyloric stenosis?
- must correct the hypochloraemic, hypokalaemic metabolic alkalosis
- endoscopic balloon dilatation (NB risk of perf)
- maximal acid suppression
- if unsuccess: do drainage procedure e.g. gastro-enterstomy or pyloroplasty and highly SELECTIVE vagotomy
what causes infantile pyloric stenosis?
hypertrophy of muscle surrounding pylorus which spasms as the stomach empties
what are the symptoms of infantile pyloric stenosis? and when does it present?
- presentation: not at birth, but in first 3-8wks
- projectile vomiting (non bilious as bile cant pass back into stomach!)
- poor feeding, weight loss, failure to thrive
how to diagnose congenital hypertrophic pyloric stenosis?
- palpating a pyloric mass in the RUQ during a feed
- visible gastric peristalsis passing from LUQ
what are the complications of pyloric stenosis
- metabolic alkalosis due to projectile vomiting and loss of H+ions from gastric juice
- so water and electrolyte deplete NEEDS CORRECTING before surgery
what is the treatment for congenital hypertrophic pyloric stenosis?
- correct U&E and fluid
- Ramstedt's pyloromyotomy
what is the most common type of small bowel diverticulum? and where?
- congenital jejunal diverticulae
- occur on mesenteric border
what is Meckel's diverticulum a remnant of?
remnant of vitellointestinal duct
where does Meckel's diverticulum occur?
on ANTEMESENTERIC border in the distal ileum
what type of epithelium does Meckel's diverticulum contain?
- gastric type epithelium which can BLEED and may cause PAIN due to gastric acid secretion
- pancreatic type epithelium
how do u make a diagnosis of Meckel's?
radionucleotide scan and laparotomy
what may an acute Meckel's diverticulum be misdiagnosed as?
What is the type of lens dislocation in Marfan's syndrome?
superiorly and medially
what is the major differential for Marfan's and what is the difference in lens dislocation and other features?
- lens: downwards dislocated
- heart not affected
- mental retardation
- respond to pyridoxine
what would the bowel sounds be like in small bowel obstruction?
give examples of SBO when operations are needed?
- suspected STRANGULATION: irredicuble hernia
- failure of resolution with conservative Rx
what are the XR features of SBO?
- smaller calibre loops
- central, multiple loops
- valvuli conniventes: folds that go from wall to wall all the way across the lumen, more regular than hausfrau
- grey: contains air and fluid
what are the XR features of large bowel obstruction
- larger calibre lumen
- peripheral loops
- hausfrau: do not go all the way across lumen, but may appear so in creation angles
- blacker: contain gas
what is the condition where there are multiple dilated air filled loops of large and small bowel and there is no clear transition pt?
what is the small bowels normal diameter?
what is the large bowels normal diameter? what is considered dilated?
what is thumb printing on XR and when is it seen?
- protrusion of rounded indentations of thickened mural folds into the lumen
- large bowel ischaemia
what is Rigler's sign?
gas outside the lumen, on both sides of the bowel wall on supine AXR
what is porcelain gallbladder? and causes?
- calcification of the GB
- due to chronic inflammation secondary to GS or adenocarcinoma
give 5 causes of pneumatobilia?
- post ERCP
- post surgery
- anaerobic cholangitis
- recent stone passage
- biliary-enteric fistula
- incompetence of sphincter of oddi
what would the ileus from local peritoneal inflammation look like on AXR? and what pathology would this indicate in the 4 quadrants of the abdomen?
- sentinel loop of intraluminal gas
- RUQ: cholecystitis
- LUQ: pancreatitis
- RLQ: appendicitis
- LLQ: diverticulitis
what are the 2 types of gas in the biliary tree (pneumatobilia?) and how would you distinguish each on AXR and how would you treat each?
- portal vein gas: goes Peripheral in liver. surgical EMERGENCY as it may imply dead gut somewhere
- biliary tree: gas will be in the centre of the liver, not emergency
In SBO, describe the symptoms
- pain: HIGHER in the abdomen
- distension: less
- vomiting: earlier
describe symptoms of LBO:
- pain: constant
- AXR shows gas proximal to blockage but not in rectum unless PR done
- if ileocaecal valve is competent (i.e. doesn't allow reflux) then pain may be felt over distended caecum
what are the signs and symptoms of ileum?
- no pain
- just constipated
- bowel sounds absent
how can you tell if the bowel is strangulated?
- sharper, more constant pain (not colicky)
- localised pain
- high WCC
how would you manage LBO, SBO, ileus, strangulation?
- LBO & strangulation: surgery soon
- LBO, ileum: manage conservatively then may need surgery
what is the immediate action taken for any obstruction?
- NGT: suck
- iv fluids: drop
- correct electrolyte abN
- NBM: rest the bowel
what further imaging can be used in obstruction and how, why?
colonoscopy but risk perforation: gastrografin - LEVEL of obstruction. therapeutic action against mild mechanical obstruction
what is closed loop obstruction? and when does this occur?
- LBO with tenderness over a grossly dilated caecum (>12cm needs urgent decompression)
- occurs when the ileocaecal valise remains competent despite bowel distension
how would you treat less urgent LBO?
water soluble enema to try to clear the obstruction and correct fluid imbalance
which tumour is polycythaemia a paraneoplastic syndrome of?
is serum amylase a prognostic test for acute pancreatitis?
what are the prognostic factors and their values for a poor prognosis of acute pancreatitis?
- PaO2 < 8kPa
- Age > 55
- Neutrophils: WBC >15
- Calcium < 2mmol/l
- Renal function: urea>16mmol/l
- Enzymes: LDH>600iu, AST>200iu/L
- Albumin>32g/l (serum)
- Sugars > 10mmol/l
which condition is barium enema contraindicated in?
what is the most common cause of vesicle-colic fistula causing pneumaturis?
if there is a chronic anal fissure, what other finding do you expect to see on PR examination?
sentinel mucosal tag externally
why cant anal fissures heal well?
hard faeces makes defaecation v.painful and spasm of sphincter so constrict inferior rectal artery --> ischaemia and healing difficult
what are the causes of anal fissures?
- hard faeces
- anal cancer
what is the treatment of anal fissures?
- conservative: stool softeners, extra dietary roughage
- medical: GTN (SE headache, post hypo), calcium channel blocker diltiazem ointment
- injection: botulinum toxin
- surgical: lateral internal sphincterotomy
what are the causes of anal fistula? and what do most start off as?
- diverticular disease
- start as perianal abscess: sepsis in anal gland - force out through canal to perianal skin or vaginal skin
what is the difference between a low and high anal fistula?
- low: fistula does not cross the sphincter muscles above the dentate line
- high: fistula does cross the sphincter muscles above the dentate line
what are the symptoms and signs of acute perianal abscess?
- rapid onset perianal pain
- skin: swollen, red
- systemic: fever, tachycardia
what investigations need to be done for anal fistula?
- 1. PR, perineum
- 2. EUA - probe through external opening of fistula to identify the tract and internal opening
- 3. end anal ultrasound with H202 if cant find tract with EUA
- 4. MRI
- 5. flexi sig: if suspect colorectal DISEASE e.g. crohns
treatment of anal fistula
- medical: antibiotics, anti inflame (if IBD)
- surgical: drain acute sepsis
- low fistula: lay OPEN track by putting metal probe into fistula and cut through tissue onto probe
- then remove all granulation tissue, allow to heal SPONTANEOUSLY (secondary intention) = FISTULOTOMY
- high fistula: SETON - large silk suture passed through fistula track and tied off on outside. TIGHTEN every 2 weeks so it cuts through to surface, with fistula healing by SCAR tissue behind it. cant lay open high fistula as will damage sphincters
what is goodsall's rule about anal fistula?
- it determines the path of the fistula track between openings
- if anterior external opening: means fistula runs directly in a straight line into anal canal
- if posterior external opening: the internal opening is always at 6o'clock i.e. it curves to the posterior midline of the canal
what are haemorrhoids?
spongy vascular cushions which line the anus and contribute to anal closure at 3, 7, 11 which are attached by smooth muscle and elastic tissue but are prone to displacement and disruption and can protrude to form piles
what factors make haemorrhoids protrude?
- effect of gravity (our erect posture)
- increased anal tone
- effects of straining at stool due to constipation
- all make the vascular cushions bulky and loose and so protrude to make piles
what colour is bleeding from piles and why?
bright red, as blood loss is from capillaries of the underlying lamina propria.
why are haemorrhoids generally painless, and when can they become painful?
- painless: no sensory fibres above dentate line (squamomucosal junction)
- painful: if they thrombose when they protrude and are gripped by the anal sphincter, blocking venous return
what are the causes of haemorrhoids
- constipation with prolonged straining
- congestion from a pelvic tumour, pregnancy, CCF, portal hypertension
- differential anal pain
where are piles located and why?
- 3, 7, 11 oclock lithotomy position
- this is where the superior rectal vein branches enter the muscle
why is having piles sometimes a vicious cycle?
- the vascular cushions protrude through a TIGHT anus
- become more congested
- so hypertrophy again to protrude again more READILY
- the protrusions then strangulate as tight anus
what is the classification of haemorrhoids
- 1st degree: remain in rectum
- 2nd degree: prolapse through anus on defaecation but spontaneously reduce
- 3rd degree: prolapse through anus on defaecation but need manual digital reduction
- 4th degree: remain persistently prolapsed
what may a patient with haemorrhoids complain of?
- bright red rectal bleeding, coating stools or dripping into pain after defaecation
- mucous discharge
- pruritis ani
- severe anaemia
- mild incontinence of flatus as there is imperfect closure of anal cushions
what actions needs to be taken in any rectal bleeding?
- abdominal examination: rule out other disease
- PR exam: external, prolapsing haemorrhoids. cannot palpate internal
- proctoscopy: internal haemorroids
- sigmoidoscopy: rectal pathology up to rectosigmoid junction
what is the treatment of haemorrhoids?
- conservative: stool softener
- inject sclerosant: 5% phenol in almond oil injected into pile above dentate line. this shrinks the H and causes scar formation SE: impotence, prostatitis
- rubber band ligation: SE bleeding, infection. cheap but needs skill
- Infra red coagulation: coagulates vessels and tethers mucosa to subcut tissue
- haemorroidectomy: excision of piles and ligation of vascular pedicles. day case may need 2 wks off work. SE haemorrhage or stenosis
- pre-op: 1 wks lactulose and metronidazole reduces pain and time off work
what are the complications of haemorrhoids?
what is the differential diagnosis of haemorrhoids?
- perianal haematoma: rupture of small vein that drains anus, may see blue tinge under skin
- anal fissure: tear in mucosa of anal canal
which chromosome is the AFP gene on? and what type of inheritance?
how is Peutz-Jeghers syndrome recognised clinically?
pigmented lesions on lips
what sort of antibiotic use do you worry about fungal infections?
PROLONGED antibiotic use (not prophylaxis)
name a contraindication to internal drainage of pancreatic pseudocyst
what clinical feature is present in over 75% of patients with pancreatic pseudocyst?
palpable abdo mass
what are the complications of acute pyelonephritis which doesn't improve with antibiotics? how to Ix and Rx this?
- obstructed infected kidney: pyonephrosis
- Ix: IVU or US
- Rx: urgent nephrostomy drainage
what would manometry of achalasia show?
high pressure non relaxing LOS
what can cause diverticula to become inflamed?
what are the complications of diverticular disease? and how to treat them?
- 1 diverticulitis: altered bowel habit LIF colic, pyrexa, high WCC, high CRP/ESR, localised or generalised peritonism. bed rest, NBM, iv fluids, analgesia, antibiotics
- 2 perforation: ileum, peritonitis +/- shock. may need laparotomy Hartmann's (temporary colostomy and partial colectomy).
- 3 form fistulae into adjacent structures: enterocolic, colovaginal, colovesical (pneumaturia, intractable UTI). Rx: colonic resection
- 4 bleed: sudden and painLESS. bleeding stops with berets. may need transfusion. Rx: embolisation/colonic resection after locate bleeding points by angio/colonoscopy. diathermy and local adrenaline injection prevent need for surgery
- 5 abscess: swinging fever, high WCC, may have localising signs. Rx: antibiotics, US drainage
- bowel obstruction
if crohn's disease is suspected what are the 2 first investigations needed to be done?
- FBC: anaemia due to malabsorption or bleeding
- colonoscopy: visualise colonic mucosa, transmural inflammation, granuloma,
which patients are more prone to diverticular disease at an early age?
what is thought to cause diverticula and how?
- low fibre: leads to high intraluminal pressures which force mucosa to herniate through muscle layers of the gut at weak points,
- adjacent to PENETRATING VESSELS
where do diverticula occur?
why are diverticula prone to perforation?
muscle atrophy so no muscular layer
what is the differential for bright red PR bleed in elderly?
- diverticular bleed
- angiodysplasia: submucosal AVM. but most in right colon. do mesenteric angiography to diagnose angiodysplasia as it shows early filling at the site of lesion, then extravasation. do therapeutic embolisation during active bleeding.
how can diverticulosis be treated?
- high fibre diet: wholemeal bread, fruit veg
- antispasmodics: mebeverine
what is the management for diverticulitis?
- initial: bowel rest, fluids only, co-amoxiclav/metronidazole/ciprofloxacin
- if oral fluids cannot be tolerated - admit:
- analgesia, NBM, iv fluids, iv antibiotics: cefuroxime and metronidazole
- imaging: ultrasound: perforation, free fluid, collections
- contrast CT: more accurate
- do NOT do colonoscopy in acute attack
- surgery: if peritonitis suppurative or faecal
what is the acute management for rectal bleeding?
- ABC resuscitaion (fluids, oxygen)
- History and examination
- Tests: FBC, LFT, U&E, clotting, amylase, CRP, group and save (NB await Hb before cross match unless unstable and bleeding)
- Imaging: plain AXR, erect CXR if suspect signs of perforation (sepsis, peritonism) or cardioresp comorbidity, if angiodysplasia suspected then angiography
- Fluids: 2 cannulae. urinary catheter. crystalloid replacement and maintenance ivi. transfusion rarely needed
- Antibiotics: if suspect sepsis or perforation - cefuroxime, metronidazole
- PPI: omeprazole as 15% are UGI bleeds
- Bed bound: pt may feel need to get out to pass stool but this could be another large bleed - result in collapse if they try to walk (postural hypo). DONT ALLOW MOBILISE AND TELL NURSE
- Stool chart: volume and frequency of motions. sample for MC&S
- Diet: clear fluids, need clear colon for colonoscopy
- Surgery: only if unremitting, MASSIVE BLEEDING
What are the main causes of rectal bleeds?
- Colorectal cancer
- IBD: UC or Crohn's
- Perianal disease
what cancers does coeliac disease predispose to?
- adenocarcinoma of small bowel
- T cell lymphoma
name 4 recognised presentations of pancreatic carcinoma
- oesophageal varices
- diabetes mellitus
what is the surface marking of the GB?
tip of the right 9th costal cartilage i.e. where R rectus sheath crosses costal margin
where may GB pain be referred to? why?
- R shoulder tip (Kehr's sign)
- as GB inflammation or distension irritates diaphragm innervated by phrenic nerve C345 which also provide sensation to R shoulder tip by supraclav nerves C345.
what are the branches of coeliac trunk?
- gastric artery
- splenic artery
- hepatic artery
what is the drainage of the coeliac axis?
splenic vein into portal vein