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  Breakdown                   Biliverdin           Bilirubin                Plasma Bilirubin                   (CHOLESTATIC) OBSTRUCTIVE JAUNDICE
     of Hb                                                         (insoluble or UNCONJUGATED)
                                                                           bound to albumin                               =  CONJUGATED bilirubin
                                                                                                                                       
                                                                                                                   Blood = conjugated hyperbilirubinaemia
                                                                                                                                       
                                                                                                                             Urine [since water sol]
  Breakdown                                                                                                                            
    of RBC                                                            Uptake into liver from                                       Dark urine
                                                                            plasma
       Spleen                                                                                                               Less conjugated bilirubin
                          A                B
                                                                                                                                       
                                                                                                                                     Bowel
         PRE-HEPATIC JAUNDICE                                                                                                          
                                                                                                                                  Pale faeces
  Excess bilirubin production:                                                                               Causes:
                                               C                     Bilirubin conjugated with                 Choledochal cyst
         A  Haemolysis                                                 gluconuric acid by                    Ciliary Atresia
         B  Liver uptake                                                  hepatocytes                        MURAL / INTRINSIC
                                                                   (soluble or CONJUGATED)
         C  Conjugation                                                                                              Liver cell transport abnormalities
                                                                                                                       Cholangitis
        = UNCONJUGATED bilirubin                                                                                      Cholangiocarcinoma
                                                                                                                      Benign stricture
            Blood = unconjugated                                                                                       Mirrizi syndrome (GS in cystic duct
             hyperbilirubinaemia                                                                                          or GB)
                                                                                                              INTRALUMINAL
        Not in urine [since water insol]                                                                               Infestation
                                                                                                                       Gallstones
                                                                                   Excreted in
  Causes:                                                                                                      EXTRINSIC
                                                                                      bile
    Physiological (neonatal)                                                                                          Portal lymphadenopathy
       haemolysis                                                                                                      Chronic Pancreatitis
    Dyserythropoeisis                                                                                                 Pancreatic C
    Glyuronyl transferase deficiency                                                                                  Ampullary/ duodenal tumour
            Gilbert’s Syndrome (2-
               7% of population)
            Criglar-Najjar
               Syndrome

                                                                             Portal                   Hydrolised by                 Stercobilogen
                          HEPATIC JAUNDICE                                 Circulation                bacterial flora
                                                                                                        in colon
  Conjugated hyperbilirubinaemia may also be caused by hepatic
  jaundice disorders though Unconjugated hyperbilirubinaemia is
  also present.

  Causes:
    Hepatocyte damage +/- some cholestasis
    Viruses                                                              Absorbed                      Urobilogen-                   Oxidised 
            Hep ABC                                                      into blood                   water sol and                  Stercobilin
            CMV                                                                                        colourless                  (brown colour)
            EBV
    Drugs
    OH hepatitis
    Cirrhosis
    Septicaemia                                                          Excreted in urine              Excreted in
    Leptospirosis                                                        (as Urobilin???)                 faeces
    Liver abscess
    A1 antitrypsin deficiency
    Wilson’s disease (Disorder of copper met  KF rings)
    Budd Chiari syndrome (Hepatic venous obstruction)
    Failure to excrete conjugated bilirubin
            Dubin Johnson syndrome
            Rotor syndrome
    Right heart failure
    Toxins
                                                                                 BILIRUBIN AND JAUNDICE…
 GALLSTONES                                                                                           Cholecystitis- see another card
 Def             Calculus formed in the gallbladder or biliary passages                              Mucocele GB
                 AKA- biliary calculus, cholelith                                                           Def: Continuous secretion of mucous + common BD
 PP              ♀>♂ (2:1), though elderly ratio is equal                                                     plug ( infection = ‘Empyema’)
                 USA / Europe / Australia > India / Far East / Africa                                       Ca secreted into GB lumen = ‘Porcelain GB’
 Cause           Fat, Female, Fair, Forty, Fertile
                 Sickle cell disease (bilirubin), Cirrhosis, crohn disease,                     WITHIN BILE DUCTS
                  Diabetes, Pancreatic disease, Hyperparathyroidism, Pregnancy                     Obstructive Jaundice
 Path         Most are mixed, but stones are classified into:                                              Def: Gallstones  cystic duct (stricturing of hepatic
              CHOLESTEROL- > in developed countries, 80%, radiolucent,                                       duct = ‘Mirrizzis Syndrome’ / Pancreatitis )
                  large, Female, Fat, Forty                                                                 Tx:  ERCP + Cholecystectomy
              PIGMENT- irregular, radiolucent, small, haemolysis                                  Cholangitis
              Only 10% are radio-opaque                                                                   Bile duct inflammation
 S&S        90% asymptomatic                                                                                SS: RUQ pain + jaundice + rigors (CHARCOT’S Triad)
            Rest  biliary colic / cholecystitis                                                            Tx:  Cefuroxime + Metronidiazole
 DDx
 Tx            IVI, NBM                                                                        WITHIN GUT
               IV Antibiotics                                                                    Gallstone Ileus
               Oral Bile Acids / Bile Salt Therapy                                                       Def: Gallstone perforates duodenum / stomach
               Lithotrypsy / ERCP + Cholecystectomy                                                      Dx: AXR- air in CBD. Small bowel fluid levels, stone
 Comp       WITHIN GALLBLADDER                                                                     Fistulae
              Biliary Colic- see another card                                                             Def: b/w GB + duodenum / stomach

WILL WESTON                                                     DON’T FORGET: http://www.uwgi.org/guidelines/main.htm                                   Page 1 of 12
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                         Dx: Abdo XR- air in biliary tree                                                             EARLY              LATE
                                                                                   Bilirubin
                                                                                                                      N/                N/               N
 BILIARY COLIC & CHOLECYSTITIS                                                     unconjugated
 Def        Main difference = inflammatory component                              Bilirubin
                                                                                                          N            N                                   
 PP                                                                               conjugated
 Cause      Gallstones  Common BD                                                Urinary bilirubin
                                                                                                          N/                                             
 Path                                                                              = dark urine
 S&S     Biliary Colic:                                                            Urobilogen
                                                                                                          N/          N                                   
            RUQ sudden onset pain- 2 hrs (<6) + jaundice                           = pale stools
         Cholecystitis:                                                            Reticulocytes          >2%          N                  N                 N
            Epigastic pain > RUQ (70%/20%)                                        LFTS
            Radiation: Peritonitis  R Scapula                                    Alkaline
                                                                                                          N                                               N
            GB mass + N/V + Jaundice                                              phosphatase
            Murphy’s sign: 2 fingers over GB, inspiration, pain, -ve left side    Y-gt transaminase      N                                               N
 DDx     Cholecystitis: PUD, Hepatitis, Liver Absess, Pancreatitis, C of Liver /   Transaminases          N                                              N
         Bile Ducts / GB, Cholangitis.                                             Lactate
                                                                                                          N                                              N
 Inv     BILIARY COLIC:                                                            dehydrogenase
         AXR             Calc stones in < 20%
         AUS                                                                       HEPATITIS
         Oral Cystography                                                          Def       Inflammation of liver  necrosis
                                                                                   PP
           CHOLECYSTITIS:                                                          Cause        VIRUSES: Hepatitis Viruses, EBV, CMV
           WCC                                                                                 IATROGENIC / DRUGS: OH, Drugs (e.g. Paracetamol)
           US             Thick GB mass- >3mm, distended GB, pericholecystic                    BILIARY DISEASE / OBSTRUCTION: Ascending cholangitis,
                          fluid + stones                                                            Cancer, Bud Chiari syndrome: Thrombus  Obstruction hep
           LFTS                                                                                     veins  congestion  disrupted function.
           Amylase                                                                 Path                  Vac          Spread        Tx                       Incubation
           Bilirubin                                                                         A                       Oral          Supportive OH           2-6 /52
           Alk Phos                                                                          B                       Blood         Supportive OH           4-20 /52
                                                                                             C                       Blood         Interferon               2-26 /52
 Tx        Biliary Colic:
                                                                                             D           () B        Blood         Interferon               6-9 /52
               Opiod (Not morphine as  pressure in sphincter of oddi)                                 
                                                                                             E                        Oral          Prevention               3-8 /52
               Prochlorperazine
               Cholecystectomy                                                   Needle stick injury risk from infected pt: Hep B (30%), Hep C (10%), HIV (0.1%)
                                                                                   Transmission for Hep B: Sexual (10%), Vertical (70%).
           Cholecystitis                                                             HEPATITIS C:
                                                                                      A Range of 6 viruses (1-6). Genotype 1 & 4 > difficult to treat than 2 & 3.
             NBM
                                                                                      OH + Hep C  Exponential inflammation and cirrhosis.
             NG decompression within 48 hrs
                                                                                      Of those infected with Hep C: 80% retain virus, 20% are clear.
              Analgesia
                                                                                      Of those 80% who are infected and retain the virus
              Antibiotics: Cefuroxime and metronidazole
                                                                                                80% clear but ½ relapse once off the drugs. 20%  Cirrhosis
              Cholecystectomy
                                                                                      Risk of Hep C transmission is 6% for both sexual and vertical.
 Comp      Chronic Cholecystitis: stones  chronic inflammation  vague
                                                                                     INTERFERON TX:
           abdominal discomfort + distension
                                                                                      Interferon Tx is 6/12 for Types 2&3 (12/12 for others + 12/52 response
                                                                                         testing). S/E for 1st 24hrs are bad, then poor for day 2, then fine during
 JAUNDICE                                                                                day 3.
 Def        Yellow appearance: skin / sclera / mucous membranes                      Interferon Benefit: B- Acute                    Not useful
             bilirubin detectable at 3mg / dL or 40 micromol/l                      Interferon Benefit: B- Chronic                  40% patients have benefit
 PP                                                                                  Interferon Benefit: C- Acute                    Unknown
 Cause      Contacts                          A Alcohol                             Interferon Benefit: C- Chronic                  20% patients eradicate disease
 Hx         Anaemia                           B Blood Anaemia / Disease           Interferons are naturally occurring proteins which are released to stimulate
            Travel                            C Contacts with Jaundice           the immune system. Also used for: Hairy cell leukaemia, AIDS-related Kaposi's
            Had it before                     D Drugs                            sarcoma, Genital warts.
            Operations                        E ERCP                             S&S         ACUTE HEPATITIS:
            Drugs                             F Foreign travel, FHx                           Jaundice- dark urine, light stools
            Extra Hepatic Causes              G Gallstones                                    Hepatomegaly
            Sexual Preference                 H Hepatitis                                     Fatigue, malaise, lethargy
            Hep C risk if haemophiliac due to many blood transfusions.                         RUQ pain, N/V, Fever / headache
 Path    See Diagram at beginning                                                              LIVER FAILURE:
 S&S     COURVOISIER’S RULE:                                                                    Oedema ( albumin) + ascites
            Silent jaundice, palpable GB = Not gallstones (may be C)                           Hepatic encephalopathy
         MURPHY’S SIGN:                                                                         Hyperoestrogenaemia
            2 fingers over GB, inspiration, pain, -ve left side = Cholecystitis                GI bleeding
         HAEMOLYTIC                                                                             Bruising (due to  circulating coagulation factors)
            Eg. Gilberts Syndrome, Dark stools + urine, Pallor- anaemia,                       Hypoglycaemia (due to  hepatic gluconeogenesis)
                Splenomegaly-  activity                                                       VIRAL HEPATITIS:
         HEPATOCELLULAR                                                                         May be prodromal flu like symptoms: Fever, Malaise,
            Disease of liver parenchyma…prevents bilirubin  bile                                  Arthralgia, Myalgia
            Viruses, Drugs, OH, Toxins, Abscesses, RHF                                         Later due to stretching of liver capsule: Nausea, Anorexia,
         CHOLESTATIC                                                                                Jaundice, Itching, Abdominal pain
            Obstruction of bile flow, pale stools + dark urine                                 Only 1/3 of Hep C Infections  S&S
            MURAL / INTRINSIC: cholangitis, cholangiocarcinoma,                   DDx       Cholecystitis, cholelithiasis, cholangitis, biliary cirrhosis, haemolytic
                Mirrizzi’s syndrome                                                          anaemia, pancreatic C
            INTRA LUMINAL: Infection, gallstones                                  Inv /     Clinical              Hepatic E: 1st sign is affected circadian rhythm.
            EXTRINSIC: Portal lymphadenopathy, Chronic pancreatitis,              Dx                              Join dots. Construct a star.
                Pancreatic C, Ampullary / Duodenal C                                         AST / ALT
                                                                                                                                                st
                                                                                                                   : Liver cell damage (In 1 week may be
 DDx                                                                                                               Obstructive patten due to swelling.)
 Inv /   FBC               Hb                                                              ALP / GGT             : Biliary epithelium damage (GGT also with OH)
 Dx      U+Es             Complications                                                     Bilirubin             
         Clotting         PT time , Haemolytic / Cholestatic                               Albumin / PT          
         LFTS             Bilirubin: conj, unconj, urobilogen                               Virology              A-  AST / ALT/ IgM
                          ALP: obstructive- from liver collecting ducts                     Auto Abs             B- HbsAg
                          AST / ALT: cell damage- constituents of                           Paracetamol           CDE- Anti HCV / HDV / HEV antibodies
                             hepatocytes                                                                           Autoimmune: Autoimmune antibodies
                                                                                             Bx
         Virology         EBV / CMV / HAV / HBV / HCV
                                                                                             US                    Dilated biliary tree, gallstones, Scarring/ vascular
         Urine            Bilirubin  in prehepatic- since water insoluble                                        flow damage of liver / GB
                             (unconjugated)
                                                                                             AXR
                          Urobilogen absent in obstructive
         US               Bile duct dilation- obstructive jaundice  ERCP
                          If not  Liver Bx
 TYPE OF              HAEM-        HEPATO-           HEPATO-          OBST-
 JAUNDICE             OLYTIC       CELLULAR          CELLULAR         RUCTIVE
WILL WESTON                                                       DON’T FORGET: http://www.uwgi.org/guidelines/main.htm                               Page 2 of 12
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 Tx                    Nutrition                                                                    Dx                                    WCC & Platelets  (hypersplenism)
                       IV fluids                                                                              U&E                         Urea & Creatinin (If U, C = bleeding
                       Tx Nausea / Pruritis                                                                                               somewhere; If U, C = Deep cirrhosis =
                        Antiviral Tx: B+C A+E                                                                                          Hetatorenal syndrome)
                        Autoimmune- corticosteroids                                                        INR                        
                        Paracetalmol overdose – N acetylcysteine                                           LFTs (may be N              Bilirubin,
                        Liver Transplant                                                                   if severely                 Transaminases
 Mx                                                                                                          damaged)                    Alk Phos- biliary epithelial damage
 Comp                                                                                                                                    GGT biliary epithelial damage + OH
                                                                                                             Albumin, PT                
 CIRRHOSIS                                                                                                   Glucose                     Gluconeogenesis
 Def                   Irreversible damage to the liver                                                     US                         Hepatomegaly / Splenomegaly.
 PP                                                                                                                                       Malignancy. Obstructive Jaundice.
 Cause                 Commonest                                                                            AFP                        Marker for Liver C
                              OH                                                                            Bx                         Dx
                              Chronic HBV and HCV infection                                                 Endoscopy                  Oesophageal Varices (Ulcer is still most
                       Others                                                                                                             common cause of GI bleed even with OV)
                              Haemochromatosis (Tanned appearance)                                          Ascitic Tap                WCC>250cm3 = Spont bacterial peritonitis
                              Chronic active hepatitis                                                                                 Protein, M&C, Cytology.
                              Sclerosing cholangitis                                                        CT:Triple Phase            Normal / Portal / Arterial
                              Budd Chiari syndrome                                                  CHILD’S GRADING OF LIVER DISEASE
                              Wilson’s disease (Copper met- blue cornea ring)                                   Excrete…               Produce….            Signs…
                              A1 antitrypsin deficiency                                             Grade         Serum               Serum      PT     Asc     Encep        Operative
                              Drugs: Amiodarone, Methyldopa                                                      Bilirubin           Albumin                                  Mortality
                              Chronic HF                                                              A           Normal             >35 g/L     <4          None                 2%
                       Unknown Cause in 30%- Cryptogenic cirrhosis                                    B       20-50 mcmol/L         30-35 g/L    4-6          Mild               10%
 Pathology:                                                                                            C        >50 mcmol/L           <30 g/L     >6         Severe               50%
   Disruption Of                Formation of               Haphazard                Widespread       Mx      GENERAL MEASURES
      Normal                    fibrous scar             regeneration of             metabolic                   Nutritional supplements: Thiamine, Vit K.
    Sinusoidal                    tissue by              hepatocytes in            dysfunction                   Protein diet (if encephalopathy),  OH
   Architecture                 Stellate cells              nodules                weight loss and               US and a-fetoprotein every 3/12 to screen for hepatocellular C
                                                                                      wasting                    Relief of symptoms
                                                                                                                            Antihistamines for pruritis
                               Alters Blood                                                                                 Oral bile acids to  entero hepatic circulation
                                                            Hepatic
                               Flow through                Function
                                                                                                                 Regular small meals may compensate for loss of hepatic
                                   Liver                                                                            storage capacity and may minimise weight .
                                                                                                                  INR: Fresh frozen plasma
                                                                                                                  Platelets: Platelet transfusion
                                                             Varices                 Plasma                    Varices: Banding and drugs.
                                                              Rupture                Proteins                SPECIFIC TX
                             Pressure in Portal           oesophagus                                            Interferon A: Improves liver biochemistry; May retard
                              Vein (PORTAL                  and rectum
                                                                                                                    hepatocellular C in HCV induced cirrhosis
                             HYPERTENSION)                  Also caput
                                                           medusae due                                           Penicillamine for Wilsons Disease
                                                           to umbilicus                                      ASCITES
                                                               shunt                                             Bedrest
         Spenomegaly                                                                                             Fluid restriction
                                                                                                                 Low salt diet
                                                                    Accumulation                                 Spironolactone-  dose every 48 hrs (Don’t want to empty
                                                                    of bilirubin &                                  intravascular vol too quickly- have to wait for interstitial fluid to
                                                 Portosystemic
         Splenic Vein                                                other toxins                                   diffuse back in)
                                                   Shunting
          congestion
                                                                                                                 Chart daily weight: Aim for weight loss of < ½ kg / day
                                                                                                                 If response if poor, add frusemide PO.
                                                                                                                 Check U&E and creatinin regularly
                                                                                                                 Paracentesis (Removal of large vol of fluid from abdo cavity).
                                    Mesenteric                                                                   Albumin: But expensive and only has 7 day half life.
   Pooling of platelets -             Vein                                  
                                    Congestion                                                               SPONTANEOUS BACTERIAL
    Thrombocytopenia                                                     Albumin
                                                                                                                 Tx: Cefuroxime + metronidiazole
                                                                                                                 Prophylaxis: Ciprofloxacin or Trimoxazole
                                                                                                     Comp        Portal Hypertension, Variceal Haemorrhage, Ascites
                                                                                                                 Spontaneous bacterial peritonitis (Caused by translocation of
                                                        Hepatic
                                                 Encephalopathy- toxin                Clotting                     gram -ve bacteria from intestinal lumen  protein rich ascitic
             Transudation of fluid into
                                                 laden blood bypasses                 Factors                       fluid. High mortality especially when liver disease advanced).
             peritoneal cavity - Ascites
                                                          liver                                                  Hepatic encephalopathy, Liver Flap (asterixis), Constructional
                                                                                                                    Apraxia- inability to draw simple shapes, Drowsiness  Coma.
                                                                                                                    Tx with Laxatives to  intestinal bacterial load. Dx with EEG (3
                                                                                                                    spike) due to ammonia from bacteria. Tx Amoxicillin to 
                                                                                                                    bacterial flora.
              Spontaneous Bacterial                                                                              Hepatorenal syndrome
             Peritonitis (due to  conc                                                                          Hepatocellular carcinoma
                anti bacterial fluid)                                              Coagulo-pathy
                                                                                                             WERNICKE'S ENCEPHALOPATHY
                                                                                                                 DEF: Assoc w OH abuse (+ other thiamine deficiency causes)
                                                                                                                 PATH Acute capillary haemorrhages, astrocytosis and neuronal
 S&S          Liver has large FUNCTIONAL RESERVE CAPACITY. Extensive                                                death in upper brainstem and diencephalon  Triad of S&S:
              damage may remain clinically undetected (COMPENSATED) until                                        S&S:
              Decompensated…
                                                                                                                            CONFUSION: Acute confusional state
                 Hand to Toe: Lemon on sticks…
                                                                                                                            OPTHALMOPLEGIA: Nystagmus, Bilateral LR Palsy,
                 Palmar erythema, Dupuytren’s contracture, Clubbing,
                                                                                                                              Fixed Pupils, Papilloedema (Rare)
                     Leuconychia
                                                                                                                            ATAXIA: Broad Based Gait, Cerebellar Signs in limbs,
                 Hair loss
                                                                                                                              Vestibular Paralysis, Peripheral Neuropathy (esp legs)
                 Kaiser rings (blue corneal), Jaundice, Plethoric face, Anaemia
                 Fetor Hepatis- acidic sweet smell breath                                                       COMP: If Untreated Transition from Reversible Wernicke’s 
                 Spider naevi, Gynacomastia, Bruising, Muscle wasting                                              Irreversible Korsakoff Psychosis ( Short Term Memory,
                 Ascites                                                                                           Disordered time appreciation, Confabulation.)
                 Hepatomegaly- nodular liver. Small if advanced                                                 INV:  Plasma pyruvate,  RBC Transketolase.
                 Splenomegaly                                                                                   TX: Thiamine (Urgent:Once amnesia, only 50% improve)
                 Caput medusae: check w finger compression- N flow towards                          Prog        5 year survival = 50%
                     umbilicus                                                                                   Poor prognostic indicators
                 Hypogonadism                                                                                              Encephalopathy
                 Peripheral oedema (due to  protein,  renin breakdown)                                                   Serum Na = <110g/L
 DDx                                                                                                                        Serum albumin = <25g/L
 Inv /        FBC                                Hb,                                                                       INR

WILL WESTON                                                                         DON’T FORGET: http://www.uwgi.org/guidelines/main.htm                               Page 3 of 12
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 INFLAMMATORY BOWEL DISEASE (grey = Crohn’s only)                                              Diverticular disease
        ULCERATIVE COLITIS                          CROHN’S DISEASE                            Colonic carcinoma or polyp
 Def    Chronic, relapsing disorder of              Chronic granulomatous                      Haemorrhoids
        rectum and colon                            disease affecting any of gut               Rectal trauma e.g. Biopsy
 PP         ♂>♀                                       ♀>♂                                  LESS COMMON:
 Men        Smoking =  risk                          Smoking =  risk                       Anal fissure
 U.C.       Incidence= >                              Incidence= <                           Massive upper gastrointestinal bleeding
 Smke       Bimodal Peaks,20-35,50-65                 Bimodal Peaks, 20-30,                  Inflammatory bowel disease
 >          Jews > Caucasians >                            >50                                Ischaemic colitis
                African US                                                                     Meckel's diverticulum
 Cause                                                                                       Hookworm, particularly in the tropics
 Path                                                                                        Infective colitis e.g. Campylobacter
 S&S    Bloody, mucus, diarrhoea, +/-               Bloody, mucus (I=, C =)                  Solitary ulcer of rectum
        tenesmus                                    Diarrhoea / steatorrhoea         Path     
        Abdominal pain / cramps-                    I= Pain due to Obstruction       S&S       UPPER Bleed:
        Defecation relieves                         Weight  since eating = pain                       Haematemesis (May be bleeding down to Lig of
        Rectum…Proctitis                            Rectal Sparing                                        Trietze…connects R Diaphragm to Coeliac Trunk,
        Sigmoid...Proctosigmoiditis                 I=Ileal Disease = 40%                                 Holding the DJ flexure in position)
        All……….Pancolitis                           C= Crohns Colitis = 30%                            Black coffee grounds when less severe
                                                    Both = 30%                                         Melena (Bacterial degeneration). UGI bleeding,
 Extra  Venous Thrombosis                           Appendicitis                                          although RHS colonic & small bowel lesions can
 Int    Clubbing, Oral Ulcers, Fatty Liver          Clubbing, Oral Ulcers, F Liver                        occasionally be responsible
 S&S    Arthritis                                                                                      Maroon Jejunum  Caecum
        Pyoderma Gangrenosum                                                                   LOWER Bleed:
 COF    Iritis                                      Renal Stones                                       Red with clots when from Colon / Rectum
        Erythema Nodosum                            Gallbladder Stones                                 Massive rectal bleeding usually from distal colon,
 PIE    Sclerosing Cholangitis (> with UC)          Sclerosing Cholangitis                                rectum or from a major bleeding site higher in GI.
 SAC    Ankylosing Spondylitis (> UC)               Ank Spondylitis                            Syncope, Oliguria (volume depletion  hypotension)
        Cholangio Carcinoma                                                                            Anaemia symptoms:  HR,  BP, Pallor, Sweating,
 DDx    Infectious colitis, arthritis, E Coli, Campylobacter, Shigella,                                   Postural drop.
        Salmonella, Colorectal C, Malabsorption syndromes                                      Evidence of liver disease
        Diverticulitis, Ischemic Colitis                                             DDx
 Inv /  FBC, U+Es, CRP, LFTs, Blood Cultures, Serum Fe +B12 Stool MC+C               Inv /   FBC            Anaemic
 Dx     AXR                     Faecal shadowing, mucosal thickening, colonic        Dx      U&Es           Renal F
                                dilation, perforation                                                       Also: Urea  due liver metabolism of blood by liver. 
        Rectal Bx               Inflammation, Ulcers, Crypt abscesses                                        Urea : Creatinine Ratio
        Barium E                Haustra, granular mucosa, shortened colon,                   PT             If suggestion of liver disease or anticoagulated pts
                                pseudopolyps,                                                LFTs       
        Colon / Sigmoid-        Rectal Sparing, Skip Lesions, Strictures,                    Image           UGI…Endoscopy: ID cause in >90%.
        oscopy                  Coblestoning                                                 Image           Sigmoidoscopy: 10% of lower G.I. bleeds occur within
        LP =UC = Crypt abscesses                   RGS STUFF = Crohn’s D                     LGI              reach of a sigmoidoscope. If -ve 
                                Rectal sparing                                                           Colonoscopy: ASAP with emergency prep of gut by
                                Granulomas                                                                   administration of 500 ml 10% mannitol, 10 mg
                                Skip lesions                                                                 metoclopramide and plenty of water. If -ve…consider:
                                Strictures                                                               Technetium scintiscan: Good at localising lesion.
        Mucosal                 Transmural inflammation                                                      Subsequent Mx would include arteriography +/or Sx
        Mucosal                 Ulcers                              Rosethorn *                          Mesenteric angiography: Sensitive test if bleeding
                                Fissures                                                                     brisk: > 1-2 ml/min
                                Fistulas                                            Tx        ASSESS USING THE ROCKALL SCORE
                               Lead Piping (haustra loss)                                     Inform Surgeons of admission.
                               Pseudopolyps                                                   O2
 *      Rosethorn ulcers: Deep ulcers which may eventually form fistula                        Protect airway + NBM
 Tx       Prednisolone                            + Prednisolone                          Cannula: Large bore in to Antecubital fossae
          Sulphasalazine (work well)             Sulphasalazine (< evidence)                          Grouping, X-match, Hg, U&Es, PT, LFT's.
          Azathioprine                           Azathioprine                              IVI (1-2 litres of colloid) + O- blood
          NMB, IV fluids, IM vits                NMB, IV fluids, IM vits                   (INR + Correct clotting: Vit K, platelet concentrate)
             Colectomy (if  = )                  Surgery never curative                    CVP line
 Mx                                                                                            Catheterise and monitor urine output
                                                                                               Nil by mouth until endoscopy
 Comp    Toxic megacolon (>UC)                   Fistula (>crohn’s)
                                                                                               H2-antagonist, e.g. ranitidine 300 mg at night
          Risk of malignancy -                  Abdominal mass (>crohn’s)
                                                                                               OGD Endoscopy for Dx
           lymphoma, carcinoma (>UC)              Steatorrhoea (>crohn’s)
                                                                                                Surgery  Thermal ablation / colectomy
                                         Inflammation
                                                                                     Tx 2    Specific Tx of Causes…
                                          Perforation
                                                                                             BLEEDING PEPTIC ULCER
                                                                                               Bleeding often stops spontaneously (in 80-90% of cases)
 GASTROINTESTINAL BLEEDING
                                                                                               Endoscopy:
 PP     Most common GI emergency: 50-120 H admission per yr per 100 000
                                                                                                          Injection sclerotherapy, e.g. with adrenaline
           35-50%       Peptic Ulcer (NSAIDs, H Pylori)
                                                                                                          Other techniques: Heater probe and laser.
           10-20%       Gastric Erosion (NSAIDs, OH)
                                                                                             MALLORY-WEISS SYNDROME
               10%      Oesophagitis (Usually with hiatus hernia)
                                                                                               Wait for the bleeding to stop spontaneously
                5%      Vascular Malformation
                                                                                               If bleeding continues then options include:
                5%      Mallory Weiss tear (Retching)
              2-9%      Varices (Liver disease, Portal vein thrombosis)                                   Oversewing at bleeding point
                2%      Cancer of the stomach or oesophagus                                               Sengstaken-Blakemore tube (Balloon Tamponade).
              0.2%      Aortoduodenal fistula (Aortic graft)                                 EROSIVE GASTRITIS
 Cause  PHARYNX:                                                                               If bleeding continues, may require Sx (partial gastric resection)
 UGI      Vomiting of swallowed blood from a nasal bleed                                      If gastritis related to NSAIDs / aspirin / OH then bleeding usually
        OESOPHAGUS:                                                                                stops quickly. Stop aspirin / NSAID and initiate PPI.
          Oesophagitis due to a hiatus hernia                                               OESOPHAGEAL VARICES…Tx in the following order
          Oesophageal varices                                                                 Endoscopy: Band ligation (tie a rubber band around) then
          Mallory-weiss tear                                                                      sclerotherapy (injection to close off vessels)
          Carcinoma                                                                           Vasoactive Drugs – Vasopressin (ADH), Terlipressin, Octreotide
        STOMACH:                                                                                   (Somatostatin Analogue).
          Gastritis - alcoholic, drug-induced, biliary, irritant                              If Endoscopic & Drug Tx Fail  Balloon Tamponade
          Gastric ulcer (20%)                                                                     (Sengstacken Blakemore Tube)
          Gastric carcinoma                                                                   Radiological - Transjugular Intrahepatic Porto-Systemic Shunt
          Benign tumours e.g. Leiomyoma                                                           (TIPPS)
        DUODENUM:                                                                              Sx: Oesophageal transection
          Duodenal ulcer (40%)                                                              LOWER GI BLEEDS:
          Duodenitis                                                                          Take a supportive 'wait-and-see' stance
 Cause  COMMON CAUSES:                                                                         Surgical colectomy or hemicolectomy
 LGI      Angiodysplasia                                                                      Colonoscopic electrocoagulation of bleeding spots
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 Prog          Find Rockall Score for prognosis of UGI Bleeds. Takes into                                    Disruption of mucosa:
                account…Age, Shock, Comorbidity, Endoscopy Dx,                               Infection         Infection: Viral, Salmonella, Shigella, Giardia
               UGI: 20% require surgery. 10% mortality from such events. 25%                Ischaemia         Ischaemia
                will rebleed after admission and of these, a third will die. Poor            Inflammation      Inflammation: Eg. IBD, Vasculitis, Cancer, OH,
                prognostic factors include old age, shock at presentation,                                      ABx, Propanalol
                varices and rebleeding.                                             Hist        Travel, Dietary, Sexual Hx
               LGI: ~ 10% die. 75% of those presenting to H will stabilise with                Clostridium Difficile is common 2/7 – 1/12 after broad spec ABx
                only resuscitative measures, e.g. blood transfusion.                S&S         ACUTE: Gasteroenteritis
                                                                                                CHRONIC: IBS
 GASTROINTESTINAL PERFORATION                                                                   BLOODY: Campylobacter, Shigella, Crohns / UC, Isc colitis
 Def      Stomach contents  peritoneal cavity ( peritionitis)                                FRESH BLOOD: Haemorrhoids, Diverticulitis, Colon C
 PP       Frequency: Duodenal > Gastric                                                        MUCUS: IBS, Colonic Adenocarcinoma
 Cause    NSAIDS often cause                                                                   PUS: IBD, Diverticulitis
 Path                                                                                          SMALL BOWEL: RIF / periumbilical pain not relieved by
 S&S      Pain                                                                                     defecation, steatorrhoea
                  Sudden severe pain                                                           LARGE BOWEL: Watery stool, +/- blood / mucus, pelvic pain
                  Distribution following content spread over peritoneum                            relieved by defecation, tenesmus, urgency
                  Initial in upper adbo then generalised                                       NON GI CAUSE: Drugs, medication
                  Shoulder tip pain due to irritation of diaphragm                 DDx      See above
          Shallow respiration                                                      Inv /       FBC, MCV, U&Es, ESR, CRP, TFTs, Igs
                  Limitation of diaphragm movement                                 Dx          Faecal Fat, Stool M+C, Barium E, Sigmoidoscopy.
                  Shock                                                            Tx          Tx cause
                                                                                                                                           +
          Board like rigidity of abdomen                                                       Oral Rehydration (if bad  saline + K + IVI)
 DDx                                                                                             Antibiotics unless infective diarrhoea
 Inv /  CXR      Air below diaphragm (50% cases)                                                Codeine: slows transit time
 Dx              If not, water soluble contrast will confirm leakage                        Specifics:
 Tx       Resuscitation                                                                      Antibiotics                  Dysentery
           Surgical Tx                                                                      5ASAs                        IBD
 Mx       Avoid NSAIDs                                                                       Enzyme supplements           Pancreatic Disease
 Comp     Peritonitis                                                                        Somatostatin                 Secretary diarrhoea caused by hormone
          Mortality 25%                                                                                                    secreting tumours

 PEPTIC ULCER DISEASE                                                               CONSTIPATION
 Def        Ulcer in wall of stomach or duodenum resulting from digestive          Def       May be self perpetuating (H2O withdrawn at distal intestine)
                action of gastric juice on mucous membrane when latter is                     N = 3/day  1 every 3 days
                rendered susceptible to its action                                            Tenesmus: Sense of incomplete evacuation
            Ulcer: Local defect or excavation, of surface of an organ or           Cause  CONGENITAL
                tissue, produced by sloughing of inflammatory necrotic tissue.                Hirschsprung’s - myenteric nerves absent from distal colon 
 PP         10% of adults                                                          C             chronic obstruction  massively dilated, faeces filled proximal
            ♂>♀ (Duodenal = 4:1, Gastric = 2:1)                                    O             colon (MEGACOLON)
         DUODENAL                           GASTRIC                                 N         Imperforate Anus, (Pyloric Stenosis, Duodenal Atresia)
            4 x > common                                                           S      OBSTRUCTION
            Young ♂                           Elderly                             T         Painful local lesions  urge to defecate: E.g. prolapsed
            90% H Pylori                      70% H Pylori, 30% NSAIDS            I             haemorrhoids, anal fissures.
            50%: ant wall, dist to            90%: lesser curve                   P         Local obstruction  pain / difficulty in defecation: E.g. Tumour
                pyloric Junction                                                    A         Stricture: IBD, Diverticulitis, Ischaemia.
 Cause                                                                             T      NEUROLOGICAL
 Path       H Pylori: Produces ammonia from urea =  pH for  survival             E         Damage to brain/ spinal cord can lead to chronic constipation /
            NSAIDS, Steroids                                                                     incontinence: E.g. Multiple Sclerosis, Peripheral Neuropathy
            Smoking ( healing)                                                           STRESS
            Blood Group O, Neurosurgery, Z/E syndrome                                        Intestinal motility may be  due to sympathetic autonomic
                                                                                                  nerve activity. People who are severely injured or otherwise
 S&S        Pain: burning epigastric / RUQ
                                                                                                  unwell may be constipated for a few days
                       Gastric: worse with food
                                                                                           THYROID
                       Duo: better with food and worse 2-3 hrs post food.                    Hypothyroidism
            Bleeding: Haematemesis, Melaena                                               IONS
            Perforation: Rebound tenderness, severe pain                                     Ca ( intestinal motility), K
            Vomiting                                                                      PILLS
 DDx     Gastritis, Gasric C, Oesophageal / Gastric varices, Oesophageal C,                   Opiates, Antidepressants, Others with anticholinergic effects
         Pancreatitis, Pancreatic C, Cholecystitis, Gasteroenteritis                          Oral iron supplements, Antacids- aluminium containing
 Inv /   Double contrast barium meal         Endo+ Bx if ulcer (since some=C)                Stimulant Laxatives: Prolonged use of Senna  Depletes
 Dx      Endoscopy and Bx                                                                         enteric neurons  Colonic atonia
         Breath Test                        Urease                                            5HT antagonists- that have been used for diarrhoea in IBS.
         [Gastrin]                          Z/E                                            ABDOMINAL SX
         Microbiology                       Gold S for H Pylori but slow                      Paralytic Ileus from abdominal surgery
 Tx          Histamine H2 Receptor Antagonists- Cimetidine                               TOO LITTLE WATER
             H+K+ ATPase (PPI)- Lansoprazole                                                Dehydration
             Antacids / Alginates (SE= constipation)                                     EXCESS FIBRE (and of course, too little)
             Colloidal Bismuth compounds (protect mucosa)-                                  Fibre: when    water   volume
 Mx         Stop smoking /  bad food /  NSAIDS /  OH                                      Fibre: when    water   volume   defecation
            H Pylori:  PPI + 2 Abs                                                              frequency + harder
            (Lansoprazole + Amoxicillin + Erythromycin 1/52).                                FASTING   reflex colonic activity +  stool volume 
            Have Lanzoprazpole in A&E and H Pylori will vanish!                                  decline in defecation frequency
 Comp       Perforation                                                            S&S       Dietary Hx, Weight loss
                                                                                              Look for Associated S&S: Rectal Bleeding, Abdominal
 DIARRHOEA                                                                                        Distension, Bowel Sounds. Most important Examination is…
 Def       Passing of excess volume of stool                                                 PR: If Stool ++: More Likely to be functional
           Usually accompanied by: Frequency of defecation, Liquidity                        PR: If Stool +/-: Less Likely to be functional i.e. obstruction 
           May contain > fat when caused by malabsorption                                        Barium / Colonoscopy
            Normal stool volume = 200-300ml/day                                   DDx    See above
 Cause  Dysmotility    motility   transit time                                   Inv /  Investigate when a new symptoms in > 40s.
        ()            Eg. Hyperthyroidism, Autonomic neuropathy w Dm,             Dx     Bloods                  FBC, U &Es, ESR, LFTS, TFTs, Ca, K
 ‘DOSI’                 Addison’s ( stress hormones)                                      Barium E                > useful than colonoscopy as IDs neoplasia
        Osmotic        Unabsorbed osmotic solutes   H20 absorption                                                 and megacolon)
                       Eg. Lactase deficiency, Disaccharide deficiency,                   Sigmoidoscopy           Mucus
                        Pancreatitis, Bile salt malabsorption (Crohn’s, ileal       Tx        Tx Cause.
                        resection, bacterial overgrowth                                        Fibre diet,  Fluids (unless obstruction / megacolon)
        Secretary      Diffuse mucosal disease  absorption << secretion                     Laxatives in following order:
                       E.g. Cholera: Stim Cl-  lumen (Na + H2O follow).                      Bulk Laxatives- FyBogel,
                        E. Coli, Neurohormones (VIP-oma, Gastrin-oma,                          Osmotic Laxatives- lactulOse, MOvicol
                        Serotonin)                                                             Stool Softeners- Arachis oil

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                    Stimulant Laxatives- Senna, (Picolax: Used for bowel prep)                      Rarely, schizophrenia
                                                                                                   MISCELLANEOUS
 VOMITING (& NAUSEA)                                                                                Normal physiological response: Stress, Travel, Pregnancy.
 Def      NAUSEA:                                                                                   Radiation therapy
           Dysporic desire to vomit                                                                Mesenteric arterial occlusion
           Often acconmpanies by distaste for food and  appetite.                                 Hepatic and biliary disease: Cirrhosis, Acute cholecystitis
           Although often precedes vomiting, either may occur in isolation.                        Pancreatic disease: Ruptured pancreas, Acute pancreatitis
          RETCHING:                                                                                 Disseminated malignancy, Hereditary spherocytosis, Testicular
           Rhythmic reverse peristaltic activity of stomach & oesophagus                             torsion, Twisted ovarian cyst
           Accompanied by contraction of abdominal muscles.                            Tx          Regard vomiting as protective mechanism: Treat Cause.
           During retching, oesophagus dilates and may accumulate                                  For treating minor event causes…
              vomitus that is subsequently expelled.                                                Motion sickness and vestibulocochlear dysfunction
          VOMITING:                                                                                          Acetylecholine (Ach) receptor antagonists
           Forceful expulsion of food out of mouth                                                          Histamine H1 receptor antagonists
           Usually accompanied by                                                                  Block stimuli to CTZ
                     Salivation,  Sweating,  HR                                                          Dopamine D2 receptor antagonists
           Vomiting different from passive regurgitation (stomach contents                                            Phenothiazides
              and partly digested food reflux  mouth).                                                                Metoclopramide (Cholinergic Effect Also 
 Path     MUSCULAR COORDINATION                                                                                           GOJ tone,  stomach emptying )
           Relaxation of Gastro-oesophageal sphincter                                              Block VC & afferents of GI tract.
           Reverse peristalsis of stomach and oesophagus (and ileum)                                        Serotonin (5HT) receptor antagonists
           Contraction of abdominal muscles and diaphragm                                                             Ondansetron
                     Intra abdominal and intra thoracic pressure                                  Mechanism of action unknown
           *Epiglottis shuts off larynx                                                                     Cannabinoids
           *Larynx drawn forward and up by muscles in jaw and neck.                    Comp        The strong propulsive forces generated during retching and
           *Soft palate drawn up  closing nasoparynx.                                               vomiting can  tear oesophageal mucosa
           *In unconscious / inebriated individuals, these protective                                       MALLORY WEISS tear  haematemesis
              mechanisms are disrupted and vomitus may be aspirated.                                         Usually superficial and heals rapidly.
                                                                                                    Chronic vomiting e.g. bulimia may lead to…
   CORTEX, THALAMUS &                                     CHEMICAL STIMULI                                   Acid damage to teeth and gums
   HYPOTHALAMUS                                               (Blood borne)                                   Fluid and electrolytes  dehydration and altered
                                                        Morphine                                               blood chemistry
       Meningitis                                      Digoxin                                             Loss of Gastric contents
       Inter-cranial pressure, migraine                HCG in pregnancy                                              Hypokalaemia
       Disgusting sites                                Systemic illness- diabetic                                    Hyponatraemia
       Strong emotions                                  ketoacidosis, uraemia.                                        Metabolic alkalosis
                                                                                                             Loss of Intestinal contents
                                                                    D2                                                 Metabolic acidosis
   Motion sickness &                                                                                Aspiration
   diseases of INNER EAR
                                                        CHEMORECEPTOR                   INTESTINAL OBSTRUCTION
                                                    TRIGGER ZONE in floor of 4th        Def      
    Ach                                              ventricle lies outside BBB.        PP       
               H1
                                                                                        Cause    Georges Cat HAD FF TITS
     Vestibulo cochlear                                                                          Small Bowel
     Nerve                                                                                        Gallstone ileus
                                                                                                  Crohn's
                         VOMITING CENTRE                                                          Herniae external/internal
                                                                                                  Adhesions
    5HT                 (Dorsal part of Medulla                                                   Foreign body- cocaine
                             Oblongata)                                                           Tumour
     Vagal &                                                                                      Intusucception
     Splanchnic Nerves                                                                            TB- accounts for 7% of small bowel obstruction
                                                                                                 Large Bowel
                                                                                                  Sigmoid or Caecal volvulus *** (Risk: Pyloric Stenosis,
   GI TRACT & OTHER VISCERA                       VOMITING                                           Congenital Bands, Paraoesophageal hernia)
      Distension                                                                                 Tumour
                                                                                                  Faeces
      Infection
                                                                                                  Diverticulitis
      Inflammation
                                                                                        Path     
 DDx         GATROINTESTINAL                                                            S&S       Anorexia
              Gastroenteritis: Short lived. Assoc with fever.                                    Nausea / Vomiting with relief (early with SB)
              Food poisoning: Infective, irritative and toxic agents.
                                                                                                  Colicky abdo pain (with SB- More constant with LB)
              GI Obstruction.                                                                    Abdominal dissention (less with SB)
             METABOLIC                                                                            Constipation (need not be absolute if obstruction is high)
              Uraemia, e.g. secondary to renal failure                                           Tinkling bowel sounds
              Hypercalcaemia                                                                     ***vomiting / non productive retching, regurgitation of saliva,
              Diabetic Ketoacidosis                                                                 failure to pass NG tube
              Addisonian crisis                                                        DDx
             NEUROLOGICAL                                                               Inv /   AXR        horizontal fluid levels
              Raised intracranial pressure, Head injury                                Dx                 *** gastric dilation + double fluid levels  laparotomy
              Meningitis, Encephalitis
                                                                                        Tx        Conservative
              Vestibular neuronitis, Meniere's disease, Benign positional
                                                                                                   Analgesia
                 vertigo, Middle ear surgery
                                                                                                  NG tube- drip & suck
             DRUG / CHEMICAL                                                                      Correct U&E imbalance
              Ipecacuanha for intentional emesis, e.g. In certain cases of                        Strangulation requires urgent surgery- within 1 hr
                 poisoning                                                                         Small bowel obstruction with gross dilation >8cm and
              Opioid analgesics                                                                     tenderness over caecum also requires urgent surgery-
              General anaesthetics                                                                  perforation is nearby!
              Cytotoxic chemotherapy
                                                                                        Mx
              Anti-parkinsonian drugs: Levodopa and bromocriptine
                                                                                        Comp
              Antiepileptic drugs
              Digoxin overdose
             POST OPERATIVE                                                             GASTRO OESOPHAGEAL REFLUX DISEASE (GORD)
              Paralytic ileus                                                          Def      Periodic episodes of gastroesophageal reflux usually
              Mechanical obstruction                                                              accompanied by heartburn and that may  histopathological 
              Agents administered, e.g. General anaesthetics, analgesics,                         in the oesophagus
                 cytotoxic chemotherapy                                                 PP       UK Prevalence: 30%
              Procedure itself, e.g. Gastrectomy causing bilious vomiting              Cause    LES dysfunction
             PSYCHOLOGICAL                                                                       Recently ingested fat in duodenum
              Bulimia nervosa, Psychogenic vomiting, Conversion disorders,                      Progesterone (pregnancy & pill)
                                                                                                 Supine position
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                Fat / Chocolate / Caffiene / OH / Smoking                                    The 4 above lead to…Premature activation of zymogen granules
                Hiatus Hernia (30% of >50s)                                                                                   
                         20%: Rolling / Paraoesophageal (GOJ remains in                                              Release of proteases
                           abdo, but stomach herniates alongside                                                               
                         80%: Sliding / Diaphragmatic (GOJ slides up into                              Digestion of pancreas and surrounding tissue.
                           chest)                                                  S&S        Pain: steady / severe / epigastric / 1-4 hrs post meal /  when
             Others                                                                              leaning forward / Radiates to back
             Oesophageal Candidiasis                                                         N/V
             Suicide attempts (Bleach, Battery acid)                                         Guarding / Rebound tenderness (may be retroperitoneal)
             Oesophageal ulcers caused by tablets are trapped above                          Fever
                 strictures: K+ supplements / NSAIDS                                          Hypovolaemia…oliguria
 Path     Develops when oesophageal mucosa is exposed to gastric contents                     Discolouration of
          for prolonged periods of time.                                                                 Flanks (Grey Turners sign- Also AAA Rupture , RTA)
 S&S         Chest Pain- 75% pts- GORD- mimicks angina                                                  Periumbilical region (Cullen’s sign- Due to Enzymes)
                         Provoked by straining / lying down                                  Erythema Albigme: Skin that is chronically exposed to infrared
             Waterbrash                                                                          radiation e.g. Hot Water bottle which may relieve pain. More
             Persistant non productive cough                                                     often with Chronic Pancreatitis.
             Dysphagia                                                            DDx     Biliary Colic, Cholecystitis, PUD, Perforated viscus, Small bowel
             Choking-  (reflux irritates larynx)                                         obstruction, Abdo , Dissecting aneurysm, Renal colic, DKA, Ectop
             Odynophagia                                                                  pregnancy rupture, Mesenteric ischaemia / thrombosis
             Loss of dental enamel                                                Inv /      O2 & ABC                  
             Hoarse voice                                                         Dx         Ca                         : Due to Lipase combining with it
 DDx      Gasritis, Gastric , Oesophageal Varices, PUD, Pancreatitis                                                        during digestion of tissue (Like soap!)
 Inv /    Endoscopy                    >40 yrs, >4 weeks                                     LDH                       
 Dx                                    + / - pH mon, + / - manometry                         Amylase                    > 1000: biliary disease
                                       (pH <4 for >6-7% study time= Dx)                                                  200-500: OH pancreatitis
          Barium Swallow               May show hernia                                       WCC                       
          FBC                          Anaemia                                               Glucose                   
 Tx          Stop smoking / OH / late meals / aggravating diet / lying flat /               Urea                      
                 that aggravate: NSAIDS, Nitrates                                             Transaminase              
             Step down Management:                                                           AXR                        Exclude perforation / obstruction
               Antacids [Mg trisilicate mix] / Alginates [Gaviscon]                          US / CT                    Pancreatic Swelling (GS, Biliary
                                                                                                                            obstruction), Peripancreatic Fluid
                           Full Dose PPI [lansoprazole]                                      ESR / CRP                 
                                                                                         GLASGOW CRITERIA- > 3 = Severe (PANCREAS)
           GOOD RESPONSE                                BAD RESPONSE                       Other score systems: Ranson Criteria; APACHE II
                                                                                           PO2                             <8kPa
         PPI maintenance dose                       Consider pH monitoring                  Age                             >55
                                                                                          Neutrophils                     > 15 x109 / litre (WBCs)
    H2 Receptor antagonists [ranitidine]           Good                Bad                  Calcium                         < 2 mmol/l
         (Help symptoms only)                    Response                 
                                                                                            Renal Function                  >16 mmol/l ((Urea after rehydration))
                                                                    (Nissen’s)
                 Antacids                                        Fundoplication
                                                                                            Enzymes: LDH, ALT             (LDH) > 600 U/I; (ALT) > 200 U/I
 Comp     BARRET’S OESOPHAGUS
                                                                                            Albumin                       <32 g/l
             (40x risk of ,  incidence in white ♂)
                                                                                            Sugars                        > 10 mmol/l
             Vomiting
             Haematemesis                                                         Tx        NBM (ng tube)
             Dysphagia                                                                      IVI (plasma expanders)
             Melaena                                                                        Pethidine (morphine constricts sphincter of oddi)
             Tx:  Laser ablation (old)                                                     O2
             Tx:  Oesophageal Resection (young)                                            ABx: Cefuroxime
          MALLORY WEISS TEAR                                                                 ERCP: gallstone removal
             Haematemesis                                                         Comp    SYSTEMIC
             Dx: Bx                                                                         Shock (Inflammation  dilation of blood vessels)
             Tx:  PPI +  Balloon dilation                                                 Systemic inflammatory response syndrome (SIRS):
          OESOPHAGITIS                                                                                 Renal failure
             Ranges from mild redness  severe bleeding and ulceration                                Paralytic ileus
              Correlation b/w symptoms and endoscopic findings                                       Vomiting
          ANAEMIA                                                                            Hyperglycaemia (Distruption of islets of Langerhans with
             Long-standing oesophagitis  blood loss  iron deficient                          altered insulin/glucagons axis)
                 anaemia.                                                                     Serum albumin conc ( Capillary permeability)
             Almost all have large hiatus hernia.                                         PANCREATIC
          BENIGN OESOPHAGEAL STRICTURE                                                       Necrosis
             Long-standing oesophagitis  fibrous strictures.                               Abscess
             Most pts:                                                                      Pseudocyst: Enzymes  breakdown of duct  allows juice to
                         Elderly, Poor oesophageal peristaltic activity, Hx of                 accumulate elsewhere e.g. in the lesser peritoneal sac (B/w
                           heart burn but not always                                            stomach and duodenum). Tx Percutaneous Drainage.
                         Dysphagia: Worse for solids than liquids                         GASTRO INTESTINAL
                                                                                             Upper GI bleeding (Gastric or duodenal erosions)
 ACUTE PANCREATITIS                                                                          Variceal haemorrhage and erosion into colon (Splenic or portal
                                                                                                vein thrombosis)
 Def      Inflammation of pancreas due to autodigestion by its own
                                                                                             Duodenal obstruction (Compression by pancreatic mass)
            enzymes due to inappropriate activation
                                                                                             Obstructive jaundice (Compression of CBD)
 PP       3% all abdo pain, 2-28 / 100,000
 Cause    Risks: Don’t GET SMASHED when Pregnant.
                                                                                   APPENDICITIS
          Gallstones (Common)
          Ethanol (Common)                                                        Def           Inflammation of vermiform appendix
          Trauma                                                                  PP             Incidence in 20s & 30s
          Steroids                                                                               common - lifetime incidence of 6%
          Mumps                                                                   Cause         Obstruction of appendix lumen
          Autoimmune                                                              Path                             Obstruction with fecalith 
          Scorpion Venom                                                                                           Distension of appendix 
          Hyperlipidaemia & Hypothermia & Heredity & Ca                                                              lumen pressure 
          ERCP (Common)                                                                                      Venous engorgement & ischaemia 
          Drugs: Asathioprine, Asparaginase, Metacaptopurine,                                                     Bacterial invasion of wall 
            Penamidine, Didanosine, Thiazide Diuretics                                                                   Inflammation 
 Path     Defective intracellular transport & secretion of pancreatic                                                    Appendicitis 
            zymogens                                                                                                       Necrosis 
          Reflux of infected bile or duodenal contents into pancreatic duct                                                Rupture 
            e.g. sphincter of Oddi, disruption by gallstones                                                                 Peritonitis
          Hyperstimulation of pancreas, e.g. OH, fat                              S&S           Pain: Central abdo colic as inflammation begins
          Pancreatic duct obstruction e.g. choledocholothiasis, tumours                         Pain: shifts to RIF as peritoneum becomes inflamed

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                Anorexia almost invariable + / - Vomiting                                                Common cause of big PR bleeds
                Constipation usual                                                                       Tx: Transfusion may be needed
                Diarrhoea may occur.                                                                     Tx: Colonic resection
                Tachcardia                                                                       5. FISTULAE
                Fever- 37.5-38.5                                                                         Colon + small bowel / vagina / bladder (giving
                Furred tongue                                                                             pneumaturia, +/- intractable UTIs)
                Lying still                                                                              Tx: Colonic ressection
                Foetor +/- flushed                                                               6. ABSESSES
                Coughing hurts                                                                           Swinging fever
                Shallow breaths                                                                          Leucocytosis
                Right Iliac fossa:                                                                       Boggy rectal mass
                         Tenderness, guarding                                                            Tx: Pelvic absess- drain rectally
                         Rebound tenderness                                                              Tx: Subphrenic absess giving no signs- urgent US.
                         PR- painful on right                                                             Anti biotics with US guided drainage may be needed
              ROSEVINGS SIGN: more pain in RIF than LIF when LIF is                              7. STRICTURES POST INFECTIVE
                 pressed.                                                                                 May form from the sigmoid colon
              Rotating a flexed right hip when supine (OBTURATOR SIGN)
                 or raising a straightened leg against resistance (PSOAS SIGN)
                                                                                    OBESITY
                 may elicit pain
                                                                                    Def           In body weight beyond limitation of skeletal / physical
 DDx       Gastroenteritis, Perforated Peptic Ulcer, Meckels Diverticulum,
                                                                                                  requirement
           Cholecystitis, Mesenteric lymphadenitis, Intestinal obstruction,
           Crohn’s, Diverticulitis, Renal Colic, Ectopic Pregnancy, Ruptured        PP         50% UK overweight, 10% obese
           ovarian follicle                                                                    £½ billion a year in treatment costs to the NHS
 Inv /     WBC                                                                   Cause     BEHAVIOURAL
                                                                                               High fat diet
 Dx        AXR               Soft tissue mass
                                                                                               Snacking
           US                Dx if +ve, but not exclusion if –ve
                                                                                               OH (Stimulating appetite,  Restraint)
           CT                Abscess formation                                                Giving up smoking
           Hx- Pelvic syndromes in ♀                                                          ENDOCRINE
 Tx            IV fluids                                                                     Hypothyroidism
               Appendicectomy                                                                Cushings
               Abs- Metronidiazole + Cefuroxime                                              Insulinoma
 Comp         Perforation  Peritonitis / Later Infertility in ♀                             DRUGS
              Appendix mass                                                                   Antidepressants
                         Tx: NBM, Abs, Delayed Appendicectomy                                 COC
              Appendix absess                                                                 Corticosteroids
                         Tx: Drainage (Laparotomy / PR), ABs                                 GENETIC
                                                                                               Prada Willi Sydnrome
 DIVERTICULAR DISEASE                                                               Path      
 Def        DIVERTICULUM: an outpouching of the wall of gut                        S&S        Underweight                    <18.5
            DIVERTICULOSIS: that diverticula are present                                      Normal                         18.5-24.9
            DIVERTICULITIS: inflammation within a diverticulum                                Overweight                     25-29.5
 PP         1/3 of Western world have diverticulosis by 60.                                   Obese                          30-39.5
 Cause                                                                                        V Obese                        >40
 Path     fibre   intra abdominal pressure  mucosal herniation                             Abnormal walk to accommodate their weight- widened stance
 S&S        Diverticulosis: Asymptomatic / alternating bowel habit / lower                        stressing the joints  Osteoarthritis (hips, knees, and
                bowel pain relieved by bowel movement / flatulence                                ankles)  Walking even more difficult  Low back pain.
            Diverticular Bleed: generally painless / signs of lower GI                        Fatigue   Physical and social activities
                bleeding                                                                       Peripheral Oedema
            Diverticulitis:                                                                   Sweating (Relatively little body surface for their weight)
            LIF pain with  bowel movement: LIF > RIF Due to more solid                       Skin disorders (moisture is trapped in skin folds)
                stool   intra lumen pressure.                                                Difficulty breathing (Lungs compressed by accumulation of
            Inflammatory mass in LIF                                                             excess fat below the diaphragm)
            Tenderness (rebound = perforation)                                     DDx      Pregnancy, Fluid overload (HF, Nephrotic syndrome, Ascites),
            Fever                                                                           Medication, Endocrine,  Muscular development
 DDx                                                                                Inv /    BMI                 Body Mass Index: Weight kg / height m2
 Inv /   PR exam                May reveal most important competing                Dx       GHR                 Girth-height ratio (waist circumference
 Dx                                 diagnoses: Pelvic inflammation, Colonic C                                       divided by height
         WCC                                                                        Mx         Diet & exercise advice (exercise prescription)
         ESR                   Diverticulitis…                                      Tx         Orlistat-  Pancreatic / gastric lipases  decreased absorption
         Sigmoidoscopy         Triad: LIF pain + fever + leukocytosis                             by 30%
         Barium enema                                                                          Sibutramine- 5HT agonist, B adrenoreceptors
         Colonoscopy                                                                           Vertical Banded Gastroplasty- pouch created from stomach 
                                                                                                   size + decreased outlet
         US / CT                CT may be > useful than US, & plain films
                                                                                               Gastric Bypass- staple across stomach rendering lower
                                    may only be useful in showing vesical
                                                                                                  stomach useless and connects top ½ to small intestine 
                                    fistulae.
                                                                                                  smaller stomach + less absorption.
 Tx         Avoid Morphine due to colonic spasm
                                                                                    Comp       Type II Dm- +113%
            See Comp…
                                                                                               Hypertension
 Mx
                                                                                               Stroke -+53%
 Comp    Diverticulitis known as the LHS Appendicitis i.e. similar complications!              Hyperlipidaemia
                                                                                               CHD
           DASH & Follow Pretty Polly…                                                         Gallstones
             1. PAINFUL DIVERTICULAR DISEASE
                                                                                                          Especially in women
                       bowel habit
                                                                                                          And non-alcoholic steatohepatitis
                      Pain: usually colicky, left sided, relieved by defecation               Caner risk
                      Nausea, Flatulence                                                      Obstructive sleep apnoea
                      TX:  fibre diet, Antispasmodics                                        Psychological consequences
                      Surgical resection is occasionally resorted to.
             2. DIVERTICULITIS                                                     CARCINOMA OF THE OESOPHAGUS
                      1 + PYREXIA                                                  PP       7th commonest cause of death from cancer in Worldwide.
                       WCC                                                                 Incidence of 15+ in Eng/Wales is 5,736 / year
                       ESR                                                                 Incidence worldwide is decreasing (c.f. Gastric C):
                      Tender colon + localised and generalised peritonism                   Most strongly linked to OH (especially spirits) and smoking.
                      TX: Bed rest, NBM, IV fluids, Antibiotics                             Distribution: Highest in China, Africa (Esp SAfrica), Iran.
                        (metronidazol, ciprofloxacin)                                        Age: Uncommon before 50. Sex: M>F (7:1)
             3. PERFORATION                                                        Risk    LIFESTYLE:  Risk ….for Squamous Cell Carcinoma i.e. Upper 2/3
                      Ileus, peritonitis +/- shock                                          OH (20x: Esp Spirits. Latency 15-20 Years)
                      Mortality: 40%                                                        Smoking: (5x) Synergistic with OH.
                      Tx: Laparotomy                                                       SOCIOECONOMIC GROUPS:  Group   Risk
             4. HAEMORRHAGE                                                                 Dietary deficiencies of Protein, VitC, Riboflavin, Trace elements
                      Sudden and painless                                                   PAST MEDICAL HISTORY
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               Achlasia, Plummer-Vinson syndrome: Oesophageal web                                  Peritoneal portion of lesser sac drapes posteriorly over
               Caustic injury (i.e. Acid ingestion)                                                stomach.
               HPV and Tylosis palmaris (hyperkeratosis with pitting of palms)                  Gastroesophageal junction limited or no serosal covering.
               GORD: Highest risk for adenocarcinoma (i.e. Lower 1/3).                          R Anterior gastric surface adjacent to left lobe of liver and
 Path          Carcinoma commences as nodule  Either papilliferous mass                           anterior abdominal wall.
                (60%), ulcer (25%), or annular constriction, usually of cardia.                  L Part of stomach adjacent to spleen, left adrenal gland,
            Historically: Majority were squamous. Adenocarcinoma                                   superior portion of left kidney, ventral portion of pancreas, and
                incidence rising rapidly and now accounts for 50%.                                  transverse colon.
                       Squamous arises in upper 2/3 of oesophagus.                              Site of lesion classified on basis of relationship to long axis.
                       Adenocarcinoma arises in region of specialised                                     40% cancers develop in lower part ….CHECK!
                          columnar epithelium (SCE) metaplasia in lower 1/3 -                              40% cancers develop in middle part
                          Barrett's oesophagus (See below).                                                15% cancers develop in upper part
          BARRETT'S OESOPHAGUS:                                                                            10% cancers involve > one part.
            Gastric / Intestinal metaplasia of mucosa of distal oesophagus.                     Recently, no of lesions discovered in prox stomach +/-
            Most often acquired condition (Rarely congenital) and                                  involving GOJ has increased.
                represents important comp of long-standing GO reflux.                Path       95% Adenocarcinomas. 3 Morphologies with Prog:
            In acquired BO, GORD  Causes squamous mucosa of                                   Fungating tumours , Malignant ulcers , Infiltrating carcinoma 
                oesophagus  Metaplastic Change  Squamocolumnar                                Vascular supply relates to routes of hematogenous spread.
                junction (ora serrata) migrates caudally.                                        Vascular supply of stomach is derived from Coeliac artery.
            Risk of Oesopageal Cancer  x 25-130 / Stricture / Ulcer                            Coeliac A  L Gastric A  Upper R Stomach.
            Dx: Endoscopy + Bx.                                                                 Common hepatic A  R Gastric A  Lower Stomach
            Invasion Progresses from Mucosa  Submucosa  Muscular                              R gastroepiploic A  Lower portion of greater curvature.
                layer  Tracheobronchial / Aorta / Recurrent laryngeal nerve.                   Lymphatic drainage relates to areas of nodal involvement.
            Metastasise to periesophageal nodes  Liver +/or Lungs                              Lymphatic drainage of stomach is complex.
            Unfortunately, by time first S&S manifest, cancer already                           Primary drainage is along celiac axis.
                spread to nodes (mediastinal, cervical, celiac) in most.                         Minor drainage occurs along splenic hilum, suprapancreatic
 S&S        1) DYSPHAGIA (Solids  Liquids)                                                        nodal groups, porta hepatis, and gastroduodenal areas.
            2) WEIGHT LOSS (50% with osophageal carcinoma).                         Cause      DIET
            3) PAIN: Epigastric / retrosternal area. May also be bone pain.                      Risk: Pickled vegetables, Salted Fish,  dietary salt,
            4) HOARSENESS: Recurrent laryngeal nerve invasion (Poor                                smoked meats.  Risk: Fruit & Vegetables rich in Vit C.
                Prog as unresectable)                                                           HELICOBACTER PYLORI INFECTION
            5) RESPIRATORY S&S: Aspiration of undigested food; Direct                           H pylori infection is assoc with chronic atrophic gastritis
                invasion of tracheobronchial tree (Poor Prog as unresectable).                   Prolonged gastritis  6x  Risk for Gastric cancer.
            Lymphadenopathy in laterocervical / supraclavicular areas                           Assoc for tumours in antrum, body, fundus, BUT not Cardia
                represents metastasis and, if confirmed by needle aspiration /                  PREVIOUS GASTRIC SURGERY
                biopsy, is a contraindication to surgery.                                        Rationale is surgery alters normal pH of stomach.
 DDx      Achalasia, Oesophageal Stricture                                                      GENETIC FACTORS
 Inv /    Barium            First-line after history of dysphagia: Characteristic:               Poorly understood: Pernicious Anaemia, Blood Gp A
 Dx       Swallow           Irregular stricture + shouldered margins, 4-10 cm        Path
                            long and often tortuous; a tracheo-oesophageal           S&S        EARLY DISEASE: No associated S&S;
                            fistula may also be demonstrated                                     Indigestion, N&V, Dysphagia, Postprandial Fullness, 
          Endo + Bx         Establishes Lesion Hist & Limits.                                       Appetite, Weight .
                            May be Tx: Dilate, so  nutrition before Sx.                        LATE COMPLICATIONS:
          Cytology          Wwashing / abrasion Tech – (Screening in China)                      EFFUSIONS: Peritoneal & Pleural;
          CT                Met: Mediastinal / Liver                                             OBSTRUCTION of the gastric outlet, gastroesophageal
          Bronchoscopy      may be needed to exclude bronchial involvement in                       junction, or small bowel;
                            upper and middle-third lesions                                       BLEEDING in stomach, O Varices, anastomosis after Sx;
          US                Met: Liver deposits                                                  JAUNDICE: Hepatomegaly  Intrahepatic. Extrahepatic.
 Mx        Management dependent on lesion level and stage of disease.                            Inanition resulting from starvation or cachexia of tumor origin.
           UPPER THIRD LESION                                                                   SIGNS RELATE TO LATE EVENTS:
            RadTx ( Dose) indicated for lesions up to 5 cm long.                               Palpable enlarged stomach with succussion splash
            Vital structures in mediastinum closely related to upper third                      Primary mass (rare)
                make Sx clearance and resection very difficult.                                  Enlarged liver,
           MIDDLE THIRD LESION                                                                   Virchow (Left supraclavicular…aka Troisier's sign)
            RadTx ( Dose) indicated for lesions up to 5 cm long.                               Sister Mary Joseph Node (Met in umbilicus- Anatomical region
            Early tumours resectable.                                                              where peritoneum closest to skin. Rare.)
           LOWER THIRD LESION                                                                    Blumer shelf (PR Met: Growth in recto-uterine/vesical space)
            Most accessible surgically; Adenocarcinomas radioresistant.                         Signs of weight loss
           EXTENSIVE DISEASE Requires Palliation Of Dysphagia:                                   Patients may have pallor from bleeding and anemia.
            Endoscopic Laser Surgery for lesions < 8 cm long                        DDx      Oesophageal Cancer, Oesophageal Stricture, Oesophagitis, Gastric
            Oesophageal Stenting (Celestin tube) for lesions > 8 cm long                     Ulcers, Gastritis, Gastroenteritis, , Lymphoma, Malignant Neoplasms
            Alternatives include: Oesophago-Gastrostomy / Oesophago-                         of Small Intestine
                Jejunostomy / Short Course Radiotherapy                              Inv /    Endos + Bx            investigation of choice
 Prog     Prognosis dependent on the site. 5-year survival figures are:              Dx       Barium Meal           Space Occupying Mass
            Upper third tumours have a 20% 5-year survival                                                         Rigidity Of Adjacent Gastric Wall
            Middle third tumours have a 6% 5-year survival                                                         Greater Curve Ulcer
            Lower third tumours have a 15% 5-year survival                                                         Ulcer with irregular borders and disruption of
          The prognosis also depends on: Size, Site, Depth, Node/Widespread                                             normal mucosal folds
          Metastases, Tumour grade, Lymphocytic response, General health.                                           Contracted, non-distensible stomach
                                                                                                                    Fundic tumours difficult to evaluate because
 CARCINOMA OF THE STOMACH                                                                                               of poor filling
 PP       4th commonest cause of death from cancer in UK                                     Mets?                 CXR. LFTS, Liver US,
                  Following bronchial, colorectal and breast.                                FBC & FOB             Anaemia: 50%; FOB +ve in vast majority
          Incidence of 15+ in Eng/Wales is 10,227 / year                            Mx          Sx: (Partial / Total gastrectomy) is only curative Tx.
          Incidence worldwide is decreasing (c.f. Oesophageal C):                               Palliation: Radiotherapy and chemotherapy are ineffective
                  Improved diet, esp fresh fruit and vegetables.  Salt .                       Palliation: May also best served surgically. Esp if obstruction /
                  Improved housing conditions, e.g. less overcrowding,                             dysphagia is complication.
                       transmission of H pylori.                                               Other procedures inc gastrojejunostomy, placing plastic tube at
          Distribution: East Asia, especially Japanese.                                            site of constriction in those with very short life-expectancy.
          Age: 50 – 70, but any age. Sex: M>F (Slight)                                          Screening by regular gastroscopy popular in Japan.
 Anat     Stomach begins at gastroesophageal J. Ends at duodenum.                               Early endoscopy considered in all dyspepsia > 35 years old
          Stomach has 3 parts, which are semidisctinct histologically:              Prog     5-year survival after Sx: 30-50% with stage II disease, 10-25% with
                                                                                              stage III disease. Sx Mortality rate at major centres < 3%.
           CARDIA            Uppermost       Mucin-secreting cells
           FUNDUS /            Middle        Mucoid, Chief, & Parietal cells.        COLON CANCER
           BODY               (Largest)                                              Def    3 principal cell biological processes which underlie the development
           PYLORUS              Last         Mucus-Producing & Endocrine cells              of cancer:  Mutation,  Proliferation,  Apoptosis
                                                                                     PP        2nd most common cause of C
               Stomach wall made up of 5 layers. From lumen out:                              Incidence: 50-60 / 100 000 UK, 30 000 cases per year
                       Mucosa, Submucosa, Muscular, Subserosal, Serosa.                       Rare in Africa and Asia (Environmental differences)
               Peritoneum of greater sac covers anterior surface of stomach.                  In West, life risk 1:50 (1:17 with 1st degree relative)
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              Synchronous (> than 1) tumours present in 2% cases
              Rectal  > ♂, Right Sided  > ♀                                       SCLEROSING CHOLANGITIS (PRIMARY)
 Risk        Diet:  Fat  Fibre                Cancer Previously                    Def     PRIMARY (See below): Characterised by chronic inflammation +
             Neoplastic Polyps                  Ulcerative Colitis                           fibrosis of bile duct.
 DNA         Age esp > 50                       Familial risk                                SECONDARY - Bile duct strictures that result from:
 CUFF                                           Familial Polyposis                               Bile Duct Stones
              FP is Autosomal Dominant                                                          Post-Operative - Especially postcholecystectomy
              Histologically, 3 Types of Adenomatous Polyp: Villous / Tubular-                  Inf: Cryptosporidium, Microsporidia, CMV in AIDS
             Villous [Most common] / Tubular (In order of Most potential for         PP          Rare disease. Unknown aetiology. M>F (7:3)
             Malignant )                                                            Assoc       Assoc: 75% Cases assoc with IBD (Esp UC: 3-4% Cases).
 Path      Dukes grading of Colorectal Cancer                                                    Also: Retroperitoneal Fibrosis, Sarcoidosis, Riedel's thyroiditis.
             A Tumour confined to bowel wall (adenocarcinoma) (95%)                  S&S         Obstructive Jaundice
             B Tumour extending through bowel wall                                   Inv         LFTs , Bx, ERCP, AutoAbdies
             C Regional lymph nodes involved                                         Mx          Tx S&S. Ursodeoxycholic acid. Sx / Transplant
             D Distant Metastasis (e.g. Liver)                                       Comp        End Stage Liver Disease.
 S&S          Mass                                                                              Biliary Strictures, Infective Cholangitis, Cholangiocarcinoma.
                                                             o
              Obstruction: N/V, Tachycardia, Sweating, BS                           Prog        Mean survival for all patients is 7 years
              Perforation                                                           BILIARY CIRRHOSIS (PRIMARY)
              Haemorrhage                                                           Def     PRIMARY: (See Below) Autoimmune disorder marked by chronic
              Fistulae                                                                      inflammation of intrahepatic bile ducts.
              Fatigue                                                                           Aka Destructive Sclerosing Cholangitis. Aka Cholangiolitis
              Lymphadenopathy- groin                                                        SECONDARY results from obstruction of the extrahepatic ducts.
           + RHS =  WAP                       + LHS =  PowerPoint (PPT)                        Bile Duct Strictures, Gallstones, Sclerosing Cholangitis
              Weight                             In bowel habit                  PP          Rare disease. Unknown aetiology. F>M (9:1). Rare under 30.
              Anaemia                            PR Bleeding                       Assoc       Autoimmune Thyroiditis, Sjogren's syndrome, CREST
              Pain- Abdominal                    PR Mass                                          syndrome, Scleroderma, RA, Fibrosing Alveolitis
                                                  Tenesmus
                                                                                     Path        Both Primary & Secondary  Micronodular hepatic cirrhosis.
 DDx
                                                                                     S&S         Pruritus & Fatigue. Later S&S include jaundice & abdo pain.
 Inv /      Fe Def Anaemia in Old ♂ = Col  until proven otherwise                  Inv /   LFTs & Lipids            ( HDL)
 Dx        FBC + Faecal Oc Bl                       Anaemia                         Dx      Liv Bx                  Diagnostic
           LFTs/ Liv US/ CXR                        Liver / Lung Secondaries                Antibodies              95% have anti-mitochondrial autoantibodies
           PR / Protoscopy                          Mass                                    ERCP                    Exclude other pathology.
           Sigmoidoscopy / Barium Enema             1/3 Tumours detected                    TFTs                     T4
           Colonoscopy (+ Bx)                       Most specific and sensitive     Mx          Tx S&S. Ursodeoxycholic acid. Sx / Transplant
 Scrn      SCREENING- Bowel Cancer Screening Programme 04/2006.                      Prog        Survival from 5-20 years depending on time of presentation.
              All (60-69) send FOB every 2 yrs. Potential to  Mort by 20%          DIFFERENCE BETWEEN THE TWO (PSC AND PBC)
              Positive  Colonocopy (/ Barium E / Flexible Sigmoidoscopy).
                                                                                        PSC: Bile duct changes both intra- and extrahepatic
              TWO TYPES OF FOB Test:
                                                                                        PSC: Antimitochondrial antibodies (AMA) absent
                       Guaiaco: Dietary restrictions (no red meat, fresh fruit,        PSC: 80–90% of patients also have IBD disease
                          iron, Vit C, aspirin or other non-steroidal rheumatic         PSC: Predominantly affects men
                          drugs for 3 /7 before). Requires 3 Evacuations.               PSC: May also affect children and adolescents
                       Immunochemical: Requires only 1 Evacuation.
 Mx           Dukes A::                   Colonic Resection (Colonoscopy            BOWEL INFARCTION (Chronic & Acute)
              Dukes B:                    6/12 later)
                                                                                     Def        Ischaemic bowel disease may be acute or chronic.
              Dukes C:                    Colonic Resection + Chemo                            Most cases result from arterial occlusion, usually of SMA.
              Dukes D:                    Palliative Care                                      Small bowel affected uncommonly.
 Prog                                                                                           Ischaemic injury to large bowel known as Ischaemic Colitis.
                                                                                     Anat:   Coeliac Axis          Duodenum (1st Part)
                                                                                     Blood   SMA                   From Duodenum (2nd Part)  Splenic Flexure of
                                                                                                                   Large Bowel.
                                                                                             IMA                   Splenic Flexure of Large Bowel  Prox Rectum
                                                                                             Int Iliac artery      Distal Rectum
                                                                                             Branches
                                                                                     Phy       Potential areas of ischaemia are watershed between supplies…
                                                                                                SPLENIC FLEXURE
                                                                                                RECTOSIGMOID REGION
                                                                                                Normally, intra-abdominal digestive organs receive 25% of CO.
                                                                                                     Hypotension causes mesenteric arterial occlusion with shunting
                                                                                                     of blood to heart and brain. Bowel can tolerate a 70%  in
                                                                                                     blood supply without damage. Mucosa is most vulnerable area;
                                                                                                     muscularis propria, the least.
                                                                                                Ischaemia, i.e. an inadequate blood supply, results in tissue
                                                                                                     hypoxia and accumulation of toxic waste products, which may
                                                                                                     cause tissue necrosis, i.e. infarction.
                                                                                               Degree of bowel damage sustained depends upon:
                                                                                                Rapidity of ischaemia and its duration
                                                                                                Extent of any collaterals
 CARCINOMA OF THE RECTUM
                                                                                                Metabolic requirements of the area affected
 PP     M=F; 1/3 Intestinal tumours. Affects > 20s, Mostly 50-70s.                              Nature of bowel flora – e.g. anaerobes such as Clostridia
 Risk   Ulcerative colitis, familial polyposis and pre-existing adenoma.                             species may produce toxins that accentuate damage
 Path   Majority Adenocarcinomas. May also be colloidal or papilliferous.            Path       Pathological features depend on severity of ischaemia.
 S&S    See CCC- Colon Cancer: LHS S&S                                                          Affected bowel appears red / purple. Often moist and dilated
 DDx    Benign rectal tumour, Carcinoma of sigmoid (prolapsed through                                with friable often haemorrhagic mucosa. Wall may tear easily
        pouch of Douglas), Uterine / Ovarian Tumours, Secondaries In Pelvis                          and perforate.
        Extension From Prostatic / Cervical Carcinoma, Endometriosis,                           In less severe lesions, there is mucosal necrosis which is
        Diverticular Disease, Lymphogranuloma Inguinale, Amoebic                                     reversible. mucosa regenerates if blood supply can be restored.
        Granuloma                                                                               In more severe injury, muscularis propria is damaged. Any
 Inv /  PR             PR reveals carcinoma 90% of time.                                             healing results in stricture.
 Dx     Sigmoid        + Bx                                                          Class      Divided into the following
        Barium E       Indicated if: growth not visible on Sigmoidoscopy, 2nd        CHRONIC MESENTERIC ISCHAEMIA (Uncommon)
                       tumour suspected, Hx of UC / Familial Polyposis.              Cause      Atherosclerotic narrowing of main mesenteric arteries.
        Rectal US                                                                              Blood supply to gut adequate during rest but inadequate during
        Mets?             FBC, U&Es, LFTs, CXR, Liv US, IVU,                                        active digestion.
 Spred  DIRECT                      Bowel Lumen, Muscular Wall, Adjacent             S&S        Colicky, Epigastric pain (30-60 mins after food); Relieved by
                                    Organs, e.g. prostate, bladder, vagina, etc                      defaecation; Food fear   Weight; abdominal bruit
        LYMPHATIC                   Inf Mes nodes. Later: Iliac / Groin / Sup Clav   Dx         Angiography / Duplex ultrasound.
        HAEMATOGENOUS               Liver / Lungs                                    Tx         Surgical reconstruction of of mesenteric arteries.
        TRANSCOELOMIC               Peritoneal Cavity Seeding                        Prog       40% recurrence rate (Even With 3 Vessel reconstruction)
 Mx     Usually Surgical. RadTx / ChemoTx if Palliative                              ACUTE: SUPERIOR MESENTERIC ARTERY OCCLUSION
 Prog   See CCC- Colon Cancer (Duke’s Staging)                                       Cause      Thromboembolic arterial occlusion
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                Mesenteric venous occlusion                                                    Painless diarrhea, Steatorrhea, Lactose / Gluten Intolerance
                Systemic vasculitis (e.g. RA, SLE, PAN, Takayasu's arteritis)     DDx       Most Important are: Coeliac Disease, Colorectal Carcinoma, Colitis.
                Cardiovascular causes (Shock, CCF, MI, AAA)                                 Biliary Colic, Chronic Mesenteric Ischemia, Diverticulitis,
                Secondary to intestinal obstruction                                         Hypercalcemia, Hyperthyroidism, Hypothyroidism, Lactose
                        Strangulated hernia                                                 Intolerance, Pancreatitis- Chronic, PUD.
                        Intussusception: Usually in children                      Inv /     Useful to screen for inflammation and other pathology: FBC, ESR,
                        Volvulus: Usually small bowel or sigmoid colon            Dx        CRP, LFTs. Others: TFTs, FOB, Anti-endomysial antibody
 S&S            HX: Classically elderly + PMHx of Cardiac or arterial disease..   Mx        Explanation and symptomatic relief helps 75% patients
                PAIN: Sudden, severe colicky abdominal pain. Occasionally,                  FIBRE CONTENT             Dietary fibre should be gradually . Soluble
                 pain is vague and insidious.                                                                          fibre e.g. isphaghula may benefit 40%. (Bran
                VOMITING & DIARRHOEA can develop, and both may have a                                                 may be no better than placebo).
                 bloody element due to slow haemorrhage into bowel lumen                     ANTISPASMODICS            Anti-muscarinic actions may relieve pain by
                Minimal initially with pain out of proportion to examination                (Esp mebeverine           moderating smooth-muscle contractions.
                 findings. However, as necrosis passes outwards from the                     hydrochloride)
                 mucosa, GUARDING, TENDERNESS, abdominal                                     PEPPERMINT OIL            For colonic spasm and bloating
                 DISTENSION and an absence of bowel sounds are apparent.                     BULK-FORMING              For constipation
                 SHOCK is a late sign.                                                       AGENTS
 DDx                                                                                        LOPERAMIDE                For diarrhoea
 Inv /  Diagnosis is often too late as clinical presentation often deceptive:                OTHERS                    TCA: (Anticholinergic effect)
 Dx     Signs deceptively sparse and Inv usually inconclusive at an early                                              Hypnotherapy, CBT
        stage. Should always be suspected in arteriopath who develops                        Exclusion diet may help e.g. wheat flour, dairy produce, tea, coffee,
        unexplained abdominal pain. Prompt laparotomy to search for 'pale                    citrus fruits, nuts, chocolate, food colourings, additives.
        and pulseless' bowel is best policy.                                       Prog         Benign condition with an excellent long-term prognosis.
        FBC             May show leucocytosis                                                  85% virtually symptom-free in short term
        U&Es            Mildly  serum amylase                                                 68% still virtually symptom-free 5 years later
                         inorganic phosphate = Intestinal infarction                          Tx response better in: F>M; Cnstipation > Diarrhoea; Short Hx;
                        Metabolic acidosis                                                     < 50% Post-infective / non-infective IBS recover over 6 years
        Imaging         AXR: Absence of bowel gas at first; later,
                            appearances of ileus, mucosal oedema and gas in        COELIAC DISEASE (aka Celiac Sprue, aka Gluten-Sensitive Enteropathy)
                            bowel wall and portal vein                             Def    Chronic disease of digestive tract that interferes with digestion and
                        Mesenteric angiography: often Dx, but difficult to do            absorption of gluten (protein in wheat, rye, barley, &, sometimes oats)
                            in moribund patient                                    PP     INCIDENCE                1:3000.
 Tx        TX ANY UNDERLYING CONDITION, e.g. AF (Caution as                              AGE                      Bimodal: 8-12/12 & 3rd – 4th Decades.
              digitalization  Splanchnic vasoconstriction)                               SEX                      F>M (Slight)
           CORRECT SHOCK: IV fluid (Monitor with CVP and Urine OP)
                                                                                          DISTRIBUTION             W Europe, Aust, USA.
           BICARBONATE may be needed to correct acidosis
                                                                                          RACE                     Rare in Africans / Asians.
           ABx Pre-operatively, e.g. cefuroxime 750mg / 6 hourly
           INTRA-ARTERIAL INFUSION of papaverine via angiogram                           FHx                      10% Prevalence in 1st Degree Relatives.
              catheter may relieve some of associated arterial spasm               Cause    
           ANALGESIA                                                              Path   Ingestion of gluten  Immunologically mediated inflammatory
           SURGERY: Lapartomy  Reverisible / Irreversible Ischaemia                     response  Damage to intestinal mucosa (Absence of intestinal villi
              (Resection / Stoma)                                                         and lengthening of intestinal crypts characterize mucosal lesions in
 ISCHAEMIC COLITIS                                                                        untreated celiac sprue)  Maldigestion & malabsorption.
 Cause     Same as ‘Acute: Superior Mesenteric Artery Occlusion’                  S&S      GASTROINTESTINAL SYMPTOMS:
                                                                                             DIARRHOEA: Common. Watery / Semiformed / Steatorrhoea.
 S&S       Hx: Vascular disease, Dm, Sx: Aneurysm, Sx: Ligation of IMA
                                                                                                 Characteristic foul smell. May  Electolyte Complications.
           PAIN: Cramp-like, LHS abdominal pain which lasts for a few
                                                                                             FLATULENCE: Due to bacterial florae feasting on undigested &
              hours, and followed by …
                                                                                                 unabsorbed food materials.
           RECTAL BLEEDING: Dark red, often without faeces, and may
              occur 2-3 times over 12 hours.                                                 WEIGHT LOSS: Variable- Some patients may compensate for
           NO ABDOMINAL MASSES.                                                                 the malabsorption by  dietary intake. Failure to gain weight is
                                                                                                 common in infants and young children.
 DDx    May be difficult to distinguish bleeding of ischaemic colitis from that
                                                                                             WEAKNESS AND FATIGUE: Usually related to general poor
        due to IBD, Diverticulitis or Carcinoma
                                                                                                 nutrition. Severe anaemia  Fatigue. Hypokalemia due to the
 Inv /  AXR      Mucosal oedema at splenic flexure, (thumb printing); A
                                                                                                 loss of potassium in the stool  Muscle Weakness.
 Dx              single segment is affected with symmetrical stricture
                                                                                             ABDOMINAL BLOATING: Pain unusual with uncomplicated
        B/En     Support x-ray; C/I in acute illness (risk of perforation)                       CD. However, bloating / cramps with excessive flatus.
        Endo     Variable appearance from mild reddening to gangrene                        EXTRA GASTROINTESTINAL SYMPTOMS:
        Hist     Intramucosal haemorrhage, Fibrosis, Haemosiderin (rare).                    ANAEMIA:  Absorption of iron / folate from Small bowel. If
                                                                                                 severe CD with ileal involvement, May be B12 absorption.
 IRRITABLE BOWEL SYNDROME                                                                    BLEEDING:  Vit K Absorption  Prothrombin deficiency.
 Def     Functional GI disorder characterized by abdominal pain and altered                  OSTEOPENIA:  Ca Absorption  Bone pain
         bowel habits in the absence of specific and unique organic pathology.               NEUROLOGIC S&S:  Ca Absorption  Motor weakness,
 PP         Prevalence: 10 -15% of Gen population. 20-30% Consult GP.                           Paresthesias with sensory loss, and ataxia. Seizures might
            F>M (2:1); Constipation predominant sufferers > common in F.                        develop because of cerebral calcifications.
            Annual incidence 1-2%. Prevalence varies minimally with age.                    SKIN: Dermatitis herpetiformis (pruritic papulo-vesicular on
 Cause   Assoc: Panic disorder, Major Depression, Anxiety Disorder,                              extensors of extremities, trunk, buttocks, scalp, neck).
         Hypochondriasis, Fibromyalgia                                                       HORMONAL: Amenorrhea, Delayed Menarche, Infertility in
 Path    Traditionally, a Dx of exclusion. No specific motility / structural                     women. Impotence and infertility in men.
         correlates have been consistently demonstrated, so IBS remains a                   SIGNS:
         clinically defined illness.                                                         ABDOMEN: Protuberant and tympanic due to distension of
 S&S     Rome II Criteria for Dx require patients must have following                            intestinal loops with fluids & gas. Possible ascites due to severe
         continuous or recurrent symptoms for at least 3 months over 1 year:                     hypoproteinemia.
           ABDOMINAL PAIN or discomfort characterized by following:                          WEIGHT LOSS: Inc muscle wasting or loose skin folds
            Relieved by defecation                                                          OTHERS: Orthostatic Hypotension, Peripheral oedema,
            Assoc with change in stool frequency                                                Ecchymoses, Hyperkeratosis or dermatitis herpetiformis,
            Assoc with change in stool consistency                                              Cheilosis and glossitis, peripheral neuropathy
           SUPPORTING SYMPTOMS include the following:                                        SIGNS OF LATENT TETANY:
            Altered stool frequency                                                                     CHVOSTEK SIGN: Tapping course of facial nerve 
            Altered stool form                                                                             Contraction of muscles of eye, mouth or nose.
            Altered stool passage                                                                       TROUSSEAU SIGN (Neuromuscular excitability due
            Mucorrhea                                                                                      to Ca  Spasms): Compression of forearm 
            Abdominal bloating or subjective distention                                                    Thumb is adducted, Fingers bunched, Wrist flexed.
           IN MORE DETAIL:                                                         DDx    Gastroenteritis, Giardiasis, Hypoalbuminemia, Hypocalcemia,
            Pain frequently diffuse without radiation.                                   Hypokalemia, Hypomagnesemia, Hypothyroidism, IBD, Iron
            Common sites of pain include lower abdomen (Esp LLQ)                         Deficiency Anemia, IBS, Malabsorption
            Symptoms may worsen in the perimenstrual period.                      Inv /  Bloods          Blood Film: Iron deficiency. B12 / Folate . MCV ,
            Overall healthy appearance, but may be anxious.                       Dx                      PTT  (Vit K )
           S&S NOT CONSISTENT WITH IBS i.e. ORGANIC PATHOLOGY:                            Biochem         Liver Function - hypoalbuminaemia in severely ill
            Onset in middle age or older                                                                 Ferritin, Vitamin D, Calcium may be reduced
            Acute symptoms: IBS is defined by chronicity.                                                Carbohydrate Malabsorption - Confirmed XTT, HBT.
            Progressive symptoms, Nocturnal symptoms                                     Bx              Jejunal biopsy: Demonstrates characteristic histological
            Anorexia or weight loss, Fever, Rectal bleeding                                               lesion (See Path: Partial / subtotal villous atrophy).
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                                               nd
                         Gluten Free Diet  2 Bx at 9-12/12  N Mucosa.                                      Therapeutic Paracentesis (4-6L)
          Immune         Gold Standard: Endomysial antibodies                                                +/- Albumin (Acts as volume expander)
                         Also,  IgA antibodies to gliadin in 80-90%.                                        Then Move to Non Tense Mx
          Imaging        Barium Follow Through: Mucosal oedema & thickened                       NON TENSE:
                          jejunal folds. US: May show splenic atrophy.                                        Rest,  Salt, Spironolactone   Weight (0.5kg/day)
          RGC            Rectal gluten challenge: Instill 10 g gluten into rectum;                           If not enough… Spironolactone +/- Frusemide.
                          Bx shows  T lymphocytes in sensitised individuals                                  Le Veen shunt (Peritoneo-Venous) for chronic cases.
          XTT            Xylose Absorption Test: D-xylose is pentose sugar                                                           3
                                                                                                 If fluid contains > 250 WBC/mm  Empirical broad spec Abx
                          (Ingestion  Jejunal absorption  Excreted                  Comp        Respiratory embarrassment when large volume ascites present
                          unchanged in urine). Absorption of xylose is measure                    Spontaneous bacterial peritonitis, esp in cirrhosis; suspect if
                          of intestine's ability to absorb monosaccharides.                            ascitic fluid leukocyte count is 500 /microlitre, or if > than 250
                         Absorption assessed from urine specimens collected.                          polymorphonuclear cells / microlitre
          HBT            Hydrogen Breath Test: Dx malabsorption of specific
                          carbohydrates. Sugars malabsorbed in SB pass to LB          ZOLLINGER ELLISON SYNDROME
                          & metabolised by COLONIC bacteria  Hydrogen                Def    Rare disorder. Characteristics
                          (diffuses rapidly across mucosa into blood Can be                    Severe peptic ulceration
                          measured in breath. Test commonly used to Dx lactose                  Gastric acid hypersecretion
                          intolerance but may be used to detect rarer conditions                Non beta cell islet tumour of pancreas (gastrinoma)
 Mx       GLUTEN-FREE DIET:                                                           PP     0.1% of duodenal ulcers. Either sex. Any age (> common at 30-50)
             Gluten found in wheat, rye, barley but not in rice and maize.           Cause
             Oats - whether toxic to patients with CD remains controversial.         Path                       Gastrinoma secretes  gastrin
          COUNSELLING:                                                                                                           
             Explaining disease, importance of diet (with regard to comps)                    Stimulating parietal cells to secrete  acid and proliferate 3-6 fold
            CLINIC FOLLOW-UP TO:                                                                                                 
             Check For Symptoms. FBC, Folate and iron                                                    So much acid that it reaches small intestine
             Manage assoc problems, e.g. dermatitis herpetiformis                                                               
             Detect And Manage complications.                                                                      Reducing lumen pH to <2
            Failure to respond may be a result of:                                                                               
             Dietary Lapse - Monitor Anti-Endomysial Antibodies                                                  Pancreatic lipase inactivated
             Associated Lactose Intolerance due to mucosal damage                                                               
             Vitamin Or Mineral Deficiency - Zn, Cu                                                                  Bile salts precipitated
             Concurrent Pancreatic Insufficiency                                                                                
             Development Of Malignancy                                                                            Diarrhoea and steatorrhoea
             Incorrect Original Diagnosis
 Comp        Lymphomas of GI Tract                                                                  90% tumours in pancreatic head / prox duodenal wall (>
            Adenocarcinomas of GI tract                                                             common). Tumour size varies from 1mm  20cm
  Risk       Small bowel carcinoma: 80x Risk                                                        > 50% multiple Approx 1/2  2/3 malignant but slow growing
  of …       Oesophageal carcinoma (< commonly- bladder, breast, brain)                             20-60% pts have adenomas of parathyroid and pituitary glands
             Splenic Atrophy                                                         S&S            Peptic ulcers: Multiple, Severe, May occur in unusual sites:
             Miscarriage / baby with a congenital malformation in untreated                                 Post bulbar duodenum, Jejunum, Oesophagus
                 pregnant women.                                                                     Poor response to standard therapy
             Short stature due to  nutrient absorption during childhood                            Short Hx
                 when nutrition is critical to growth and development.                               Bleeding and perforation common
                                                                                                     Diarrhoea in 1/3 pts
 ASCITES: DIFFERENTIAL DIAGNOSES                                                                     Barium meal showing abnormally coarse gastric mucosal folds
 Def       Abnormal collection of fluid in peritoneal cavity.                        DDx
           Gravity  Collection in flanks of supine pt:                              Inv /     Aspiration   Gastric Asp: Confirms hypersecretion of acid
                      When > 2 L accumulated – Percussion dull in flanks.            Dx        Serum        Serum gastrin levels  (10-1000 fold)
                      As fluid , dullness is detectable closer to the middle                  Other        Secretin inj does little / nothing to gastrin levels in N
                          line + abdominal distension + umbilical inversion                                  pts: With Syndrome there is paradoxical  in gastrin
                       An area of central resonance will always persist.                      Imaging      Tumour localisation:
 Cause   Classified with respect to protein content of peritoneal fluid.                                        Endoscopic ultrasound
 Trans:  Result of  hydrostatic pressure forcing fluid out of blood vessels.                                   Radio labelled somatostatin receptor
   <3g     HEART: Cardiac Failure, Constrictive Pericarditis, Tricuspid Inc                                         scintigraphy
  Prot /   HYPOPROTEINAEMIA: Nephrotic Synd, Liver F, Budd Chiari.                   Tx           30% small and single tumours can be localised and resected.
 100ml     Ovarian Tumours, e.g. Meig's syndrome (also pleural effusion)                          PPIs heal ulcers and relieve symptoms: > N dose required
  Exud:    INTRA-ABDOMINMAL CANCER: (Liver C, Mesothelioma…)                                      Octreotide injections: Reduces gastrin secretion
  > 3g     INFECTION: Pyogenic, Tuberculosis (Tuberculous Peritonitis)               Prog         5 year survival is 60-75%
  Prot /   INFLAMMATION: Pancreatitis
 100ml     IMMUNOLOGICAL: Lymphoedema
           Myxoedema
 Other     Chylous ascites occurs with massive obstruction of abdominal
               lymphatic drainage. It is a milky white ascites, rich in
               chylomicrons from mesenteric lymphatics. Usually 2o to
               malignant involvement of para-aortic lymph nodes by
               lymphoma or metastatic testicular tumour.
           Less frequently, it is caused by:
           Primary Fistula – Tx: Close with nonabsorbable sutures
           Primary lymphatic disease
           Other secondary causes:
                      Post-radiation obstruction
                      Postoperative - very rarely
           When surgery is unsuccessful use Leveen shunt
 Path
 DDx     Abdo Distension: Fat, Fluid, Flatus, Faeces, Foetus, F**kin big tumour
 Inv /   US
 Dx      Para-         30 - 50 ml Fluid withdrawn.
         Cenesis         Protein content: Albumin & Total Protein
                         Malignant cells, Bacteria, WBCs, Glucose
           If  WCC, i.e. > 250/mm cubed, which is predominantly
               polymorphs, suggestive of spontaneous bacterial peritonitis..
           > One type of organism suggests possible bowel perforation or
               contaminated sample.
           Serum-Ascites Albumin Gradient: Calculated by subtracting
               [albumin] of ascitic fluid from [albumin] of serum specimen
               obtained on same day. Gradient of > 1.1 g / dL = Portal HT.
         Amylase       Pancreatic ascites & gut perforation in peritoneal cavity
         Smear         Tuberculous smear and culture
 Mx      Management in Cirrhosis
           Para-Cenesis then whether ascites is Tense / Non Tense…
           TENSE:
WILL WESTON                                                        DON’T FORGET: http://www.uwgi.org/guidelines/main.htm                                Page 12 of 12

				
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