Terms in this set (264)
Causes of gallstones
1. high cholesterol in bile
2. products that promote crystallisation of cholesterol
3. gallbladder stasis
Risk factors for gallstones
Inhibitors of sludge formation
Exacerbators of sludge formation
rapid weight loss/fasting
reduced bile production
drugs (clofibrate, OCP)
What is the likelihood of sludge going on to form stones?
How long does it take for a stone to form (from the beginning of the whole process)?
What 2 outcomes can happen to sludge?
reabsorption or stone formation
Formation of cholesterol and mixed stones
imbalance between bile salts/lecithin and cholesterol allows cholesterol to precipitate
Formation of pigment stones
excess circulating bile pigments
in what condition would someone have excess circulating bilirubin
What proportion of people present with symptoms from gallstones?
What proportion of people have no symptoms from gallstones?
What causes biliary colic?
temporary blockage in the cystic duct
What causes acute cholecystitis?
prolonged blockage of the cystic duct
What causes acute ascending cholangitis?
blockage of common bile duct
why does pain from gallstones radiate to the right shoulder tip?
diaphragmatic irritation (C3/4/5)
where does gallstone pain radiate to?
back and right shoulder tip
When does biliary colic typically occur?
after eating a large/fatty meal,
typically mid-evening and lasts until the early hours of the morning.
what are the features of biliary colic?
intermittent RUQ/epigastric pain
nausea and vomiting
what examination findings would you expect for biliary colic?
HR and BP normal
Management of biliary colic
typically resolves itself
fluid (if vomiting)
What is acute cholecystitis?
acute inflammation of the gallbladder
Why does gallbladder distention occur in cholecystitis?
increased mucus secretion
What blood test can help differentiate between biliary colic and acute cholecystitis?
↑ in cholecystitis
normal in biliary colic
gold standard test for gallstones?
what are the features of acute chlolecystitis?
constant RUQ pain
nausea & vomiting
what examination findings would you expect for acute cholecystitis?
management of acute cholecystitis
Possible complications of acute cholecystitis
what is acute ascending cholangitis?
severe infection of the biliary tree
possible causes of acute ascending cholangitis
gallstone in CBD
What organisms usually cause infection in acute cholangitis?
Altered mental state
What are the symptoms of obstructive jaundice?
yellow discolouration of sclera and skin
Why does obstructive jaundice cause pale stools?
reduced conversion of bilirubin to stercobilin
Why does obstructive jaundice cause dark urine?
normal bilirubin route is blocked, bilirubin goes to systemic circulation, converted to urobilinogen in the kidney, leading to darker urine
Clinical presentation of acute ascending cholangitis
altered mental state
what examination findings would you expect for acute ascending cholangitis?
Management of acute ascending cholangitis
admission to hospital
IV antibiotics (
urgent endoscopic biliary drainage
(surgical drainage only if endoscopic not effective)
What causes gallstone pancreatitis? (where is the stone?)
Gallstone stuck in Ampulla of Vater
What is gallstone pancreatitis
irritation to the pancreas caused by the blockage of pancreatic enzymes and bile by a gallstone
What is Grey-Turner's sign?
bruising in the flanks
What causes Grey-Turner's sign?
What is Cullen's sign?
bruising around the umbilicus
What causes Cullen's sign?
pancreatic enzymes tracking along the falciform ligament, digesting subcutaneous tissues around the umbilicus
What is gallstone ileus?
bowel occlusion by gallstones
clinical presentation of acute pancreatitis
severe upper abdominal pain
what examination findings would you expect for acute pancreatitis?
tender upper abdomen
upper abdominal or generalised peritonism
What investigation would confirm diagnosis of pancreatitis?
definition of dyspepsia
a range of upper GI symptoms lasting ≥4 weeks including
- upper abdominal pain
- nausea or vomiting
hot, retrosternal pain radiating upwards
pain/discomfort in stomach associated with difficulty digesting
the movement of stomach contents (usually acid) into the oesophagus
gastro-oesophageal reflux disease (GORD)
gastroscopy proven oesophagitis and gastric acid regurgitation
function of parietal cells
secretion of HCl, intrinsic factor, calcium, sodium and magnesium
function of peptic (chief) cells
secretion of pepsinogens, mucin and gastric lipase
function of surface mucosal cells in cardia and pylorus of stomach
secretion of mucus and bicarbonate ions
function of antrum of stomach
secretion of gastrin
function of gastrin
stimulates parietal cells to secrete HCl secretion
functions of vagus nerve in relation to the GI system
stimulation of acid secretion via acetylcholine, stimulation of satiety to hypothalamic nuclei
No food buffering and lowest acidity at this time- patients can be woken with heartburn as a result
aggravating factor for acid reflux
lying down flat
red flag symptoms
acute GI bleeding
unintentional weight loss
iron deficiency anaemia
age >55 with new onset dyspepsia
Barrett's oesophagus dysplastic change
squamous --> columnar epithelium
risk factors for Barrett's oesophagus
Men > 50 years
lifestyle modifications for dyspepsia
- Weight loss
- Dietary fat reduction
- Smoking cessation
- Reduce alcohol consumption
- No food 3 hours before bed
- Frequent, moderate amount of food
- Elevate bed-head
mechanism of action of antacids
alkaline medications neutralise gastric acid, alginates provide a protective layer that floats on top of gastric contents reducing reflux
Example of an antacid
mechanism of action of H2 receptor antagonists
competitively block histamine 2 receptors, blocking the stimulation of parietal cells to produce gastric acid
Examples of H2 receptor antagonists
effect of H2 antagonists on liver metabolic pathways
inhibit cytochrome p450 pathway
side effects of H2 receptor antagonists
increased risk of pneumonia
mechanism of action of Proton Pump Inhibitors
inhibit ATPase pump, sostops H+ ion secretion thus reducing acid production by 95-99%
side effects of PPIs
higher risk of CAP and C. difficile infection
What is H.pylori? (inc Gram stain)
curved, gram-negative, rod shaped bacterium
What is H.pylori associated with?
duodenal ulcers (90%)
gastric ulcers (60-70%)
Transmission of H.pylori
What is H.pylori a risk factor for?
gastric cancer and pancreatic cancer
Tests for H.pylori (3)
carbon-13 urea breath test
campylobacter-like organism test
1st line treatment for H.pylori
7 days, 2x/day course of
PPI + amoxicillin + clarithromycin/metronidazole
(no amoxicillin if pen allergic)
2nd line treatment for H. Pylori
PPI + amoxicillin + clarithromycin/metronidazole (whichever not used previously)
(if pen allergic --> levofloxacin)
could also use tetracycline or quinolone
Pain pattern in gastric ulcer
worse with food/1-2 hours after eating
Demographic for gastric ulcers
middle aged/older population
Demographic for duodenal ulcers
Pain pattern in duodenal ulcers
epigastric pain 2-5 hours after eating (nocturnal pain more common)
definition of hernia
a bulge or protrusion of an organ through the structure or muscle that usually contains it
weak spot for hernias in males
inguinal canal (where spermatic cord enters scrotum)
weak spot for hernias in females
round ligament of uterus
Risk factors for hernias
- male gender (8:1 ratio M:F)
- increasing age
- family history
- premature birth
- previous repair
hernia through line alba in the epigastrium, midline from diploid process to umbilicus
herniation through scar tissue (including previous hernia repair)
herniation through Spigelian fascia (inferior and lateral to the umbilicus)
risk factors for Spigelian hernias
age >40 years
main complication of Spigelian hernia
content of the herniated sac reduces spontaneously or can be pushed back manually, positive cough impulse
contents of the herniated sac cannot be returned to the peritoneal cavity either because of adhesion between the sac and contents or because of narrowing of the neck of the sac
irreducible hernia with normal blood supply
irreducible hernia with compromised blood supply
hollow viscus trapped within the herniated sac causing obstruction, blood supply may or may not be intact
anterior wall of inguinal canal
aponeurosis of external oblique, internal oblique (lateral 1/3rd)
posterior wall of inguinal canal
fascia transversalis,conjoint tendon (medial 1/3rd)
superior wall of inguinal canal
arching fibres of internal oblique, transverse abdominis
inferior wall of inguinal canal
inguinal ligament, lacunar ligament (medial 1/3rd)
location of inguinal hernias
superior and medial to pubic tubercle
when do indirect hernias develop?
why do indirect hernias develop?
patent processus vaginalis
where do indirect hernias develop?
superior and medial to pubic tubercle, can travel to scrotum
contents of indirect hernias
omentum or bowel
when do direct hernias develop?
acquired, usually elderly population
where do direct hernias develop?
why do direct hernias develop?
weakness of the posterior floor of the inguinal ligament + raised intra-abdominal pressure
contents of direct hernia
Medial boundary of Hesselbach's triangle
lateral border of rectus muscle
Lateral boundary of Hesselbach's triangle
inferior epigastric artery
Inferior boundary of Hesselbach's triangle
location of femoral hernia
Superior border of femoral triangle
medial border of femoral triangle
adductor longus muscle
lateral border of femoral triangle
when do umbilical hernias occur?
congenital, detect at birth and 8-week check
when do paraumbilical hernias occur?
complication of umbilical and paraumbilical hernias
strangulation (due to small neck)
symptoms of hernia
lump/bulge in area (more obvious when upright and on straining)
pain radiating to testicles
Management of reducible asymptomatic hernia
conservative (watch and wait)
Management of reducible but symptomatic hernia
surgery (if fit)
truss (if unfit)
Management of non-reducible hernia
surgery (may require bowel resection)
urgent if suspected strangulation
Management of hernia in children
always repair in children
- risk of strangulation/obstruction
Surgery for unilateral hernia repair
open hernia repair with mesh
Surgery for bilateral hernia repair
laparoscopic inguinal hernia repair with mesh
differential diagnosis for epigastric pain
differential diagnosis for RUQ pain
R lower lobe pneumonia
differential diagnosis for LUQ pain
L lower lobe pneumonia
differential diagnosis for central abdominal pain
abdominal aortic aneurysm
differential diagnosis for RLQ pain
differential diagnosis for LLQ pain
differential diagnosis for suprapubic pain
where is the visceral peritoneum?
pain originating from irritation of visceral peritoneum
deep, dull and poorly defined
innervation of visceral peritoneum
where is the parietal peritoneum
underneath abdominal wall
innervation of parietal peritoneum
pain originating from parietal peritoneum
sharp and well-localised
what is colicky pain?
cyclical on-off pain,
occurs as a result of contraction of a smooth muscle tube against an obstruction
characteristics of peritonitis
continuous severe pain
worse upon movement
what is the main pathology to think about in cases of pain out of proportion to signs?
features of mesenteric infarction
pain out of proportion to signs
associated symptoms of mesenteric infarction
nausea and vomiting
constipation or diarrhoea
absence of bowel sounds
What would you be looking for in an FBC for a patient with an acute abdomen?
What would you be looking for in an amylase for a patient with an acute abdomen?
What would you be looking for in LFTs for a patient with an acute abdomen?
What would you be looking for on ABG for a patient with an acute abdomen?
metabolic acidosis (mesenteric infarction)
what would you be looking for on urinalysis for an acute abdomen?
haematuria (renal stones)
what would you be looking for on abdominal X-Ray for an acute abdomen?
faecal loading (constipation)
dilated bowel loops (obstruction)
dilation of biliary tree (gallstones)
calcification of an AAA
what would you be looking for on erect chest X-Ray for an acute abdomen?
free air under diaphragm (perforation)
what would you be looking for on USS for an acute abdomen?
trauma (liver or spleen)
possible causes of appendicitis
obstruction by faecolith
typical clinical presentation of acute appendicitis
abdominal pain (initially dull and around umbilicus, progressing to sharp well-localised pain)
nausea and vomiting
atypical presentation of acute appendicitis
Where is McBurney's point?
2/3rds between umbilicus and ASIS
What is Rovsing's sign?
pressing in LIF elicits pain in RIF
types of incisions for appendicectomy
grid-iron incision (McBurney's incision)
typical feature of an abscess
gram-positive anaerobic bacillus
factors that stimulate gastric acid production
vagal nerve stimulation
factors that inhibit gastric acid production
somatostatin (inhibits histamine)
source of gastrin secretion
G cells in strum of stomach
stimulus for gastric secretion
distension of stomach
actions of gastrin
increase HCl, pepsinogen and intrinsic factor secretion
increases gastric motility
source of CCK
I cells in upper small intestine
stimulus for CCK secretion
partially digested proteins and triglycerides
actions of CCK
increases secretion of pancreatic juice, contraction of gallbladder and relaxation of sphincter of Oddi
decreases gastric emptying
source of secretin
s cells in upper small intestine
stimulus for secretin secretion
acidic chyme, fatty acids
actions of secretin
increases secretion of bicarbonate from pancreas and hepatic duct cells
decreases gastric acid secretion
source of vasoactive intestinal peptide
small intestine, pancreas
stimulus for vasoactive intestinal peptide secretion
actions of vasoactive intestinal peptide
stimulates secretions by pancreas and intestines
inhibits acid and pepsinogen secretion
source of somatostatin secretion
D cells in the pancreas and stomach
stimulus for somatostatin secretion
fat, bile salts and glucose in intestinal lumen
actions of somatostatin
decreases acid, gastrin and pepsin secretion
decreases pancreatic enzyme secretion
decreases insulin and glucagon secretion
stimulates gastruc mucous production
what is an anal fissure?
longitudinal or elliptical tears of the squamous lining of the distal anal canal
risk factors for anal fissures
STDs e.g. HIV, syphilis, herpes
symptoms of anal fissures
sharp pain on defecation
bright red rectal bleeding
management of acute anal fissure
high fibre diet
high fluid intake
management of chronic anal fissure
+ topical GTN
if not effective after 8 weeks refer for surgery or botox
Meckel's diverticulum rule of 2s
2% of population
2 inches long
2 feet from ileocaecal valve
2x more common in men
2 tissue types involved
intraluminal causes of dysphagia
extraluminal causes of dysphagia
functional causes of dysphagia
risk factors for oesophageal cancer
achalasia (long standing)
male > female
what types of cancer occur in the oesophagus?
squamous cell carcinoma
features of oesophageal adenocarcinoma
most common type of oesophageal cancer
more likely in patients with a history of GORD or Barrett's
where are the majority of oesophageal tumours located?
middle 1/3rd of oesophagus
clinical presentation of oesophageal cancer
cough/recurrent chest infections
what is first line investigation for oesophageal cancer?
OGD + biopsy
what is achalasia?
failure of relaxation of the lower oesophageal sphincter and loss of peristalsis
what is a long term risk of achalasia?
increased risk of malignancy
management of achalasia
endoscopic balloon dilatation (gold standard)
causes of oesophageal strictures
long standing GORD
what are the 2 most common causes of death from cancer in developed countries?
factors linked to colorectal cancer
what genetic conditions are linked with colorectal cancer?
familiar adenomatous polyposis
hereditary non-polyposis colorectal cancer
features of hereditary non-polyposis colorectal cancer
right sided cancers in under 50s
history of gynaecological malignancy
what type of colorectal cancer is most common?
adenocarcinoma (evolved from polyps)
what polyp factors increase risk of cancer?
clinical features of right sided colorectal cancer
iron deficiency anaemia
clinical features of left sided colorectal cancer
altered bowel habit
clinical features of rectal cancer
fresh red rectal bleeding
TNM staging - T1
tumour has invaded submucosa
TNM staging - T2
tumour has invaded muscularis propria
TNM staging - T3
tumour has invaded through muscular propria, into subserosa
TNM staging - T4
tumour has invaded visceral peritoneum, into other organs or structures
TNM staging - N0
no lymph nodes involved
TNM staging - N1
<4 lymph nodes involved
TNM staging - N2
>4 lymph nodes involved
TNM staging - M0
no distant metastases
TNM staging - M1
distant metastases present
what is Crohn's disease?
chronic transmural inflammation that can affect any part of the GI tract
what gene is associated with Crohn's disease
risk factors for Crohn's disease
diet (high sugar, low fibre)
where in the GI tract is most commonly affected in Crohn's disease?
What inflammatory cells are present in Crohn's disease
features of Crohn's disease
affects whole thickness of bowel
can get fistulae
presentation of Crohn's disease
failure to thrive
colicky abdominal pain
inflammatory mass in RIF
features of chronic Crohn's disease
What does a cobblestone appearance on barium swallow signify?
ulceration and oedema (Crohn's disease)
What do rose thorn ulcers signify?
transmural inflammation (Crohn's)
complications of Crohn's disease
small bowel obstruction
medical treatment of mild Crohn's disease
medical treatment of acute Crohn's disease
corticosteroids (oral prednisolone/hydrocortisone enemas)
medical management of acute severe Crohn's disease
management of severe refractory Crohn's disease
What medication is used to maintain remission in Crohn's disease
surgical options for management of Crohn's disease
ileocaecal or segmental resection
partial or total colectomy
treatment of anal complications
rate of success of surgery for Crohn's disease
complication of bowel resection
small bowel syndrome
what gene is associated with ulcerative colitis?
what layers of the bowel does ulcerative colitis affect?
mucosa and submucosa
manifestations of IBD in the eye
manifestations of IBD in the joints
manifestations of IBD in the skin
manifestations of IBD in the liver
chronic active hepatitis
primary sclerosis cholangitis
what does a 'lead pipe colon' signify?
loss of haustra
what size does a colon have to be to be defines as grossly dilated (toxic megacolon)
initial management of toxic megacolon
who is most at risk of UC developing into malignancy?
early onset UC (<30 years)
long standing disease (>10 years)
what type of cancer can develop from ulcerative colitis?
what is Mirizzi syndrome?
common hepatic duct obstruction caused by extrinsic compression from a gallstone in the cystic duct or neck of gallbladder
primary sclerosis cholangitis
chronic inflammation and fibrosis of intrahepatic and extrahepatic bile ducts
who is PSC more common in?
primary biliary cholangitis
slowly progressive autoimmune disease (may extend over many decades), involves destruction of small interlobular bile ducts resulting in intrahepatic cholestasis and cirrhosis
who is PBC more common in?
episodes of vertigo last for seconds, no associated auditory symptoms
benign paroxysmal positional vertigo
episodes of vertigo last for days, no associated auditory symptoms
episodes of vertigo last for hours, associated tinnitus and hearing loss
causes of conductive hearing loss in children
symptoms and signs of acute otitis media
otorrhoea (if perforated)
symptoms/signs of conductive hearing loss due to wax
causes of sensorineural hearing loss
noise-induced hearing loss
inflammatory disease (measles/mumps/meningitis/syphilis)
wax on the attic of the ear canal should raise suspicion of